Reconsidering Regular Medications at End of Life

Roxanne Nelson, BSN, RN

October 27, 2016

There appear to be very few discussions about discontinuing potentially inappropriate medications at the end of life, concludes a Dutch study published in the Journal of the American Geriatrics Society.

"In practice, reconsidering an individual's medication use in the last phase of life seems to be rare," say the authors, led by Eric C.T. Geijteman, MD, from the Department of Public Health, Erasmus University, Rotterdam, the Netherlands.

"Therefore, people often take multiple medications that may not have beneficial effects in view of their limited life expectancy and changing organ function," they note. These potentially inappropriate medications may cause side effects, and they also involve costs.

Medications that focus on prevention and treatment of illnesses should be reconsidered when life expectancy is only months or weeks, the authors comment.

Interview Details

For their study, Dr Geijteman and colleagues interviewed 17 patients, 12 relatives, 20 clinical specialists, and 12 general practitioners. All patients had an estimated life expectancy of under 3 months.

Three of the 17 patients were still alive 6 months after the interview, but the others died an average of 55 days afterward (range, 5 - 117 days). Most had cancer (n = 12), and the average age was 71 years (range, 47 - 91 years).

Overall, the patients, their relatives, and physicians felt that ideally, potentially inappropriate medications should be discontinued at the end of life. Both the patients and their relatives reported that they were willing to discontinue medications.

However, patients also said that stopping medication might give them the feeling that their physician had given up on them.

One question was, "Imagine that the doctors had discussed such matters with you at an earlier stage, how would you have felt about it then?"

A patient gave the following reply: "Yes, I find that difficult. No, I believe I would then have felt something like 'Guys, do you want to get rid of me or something?' [chuckles]."

When interviewed, physicians discussed some of their reasons for not considering withdrawal of potentially inappropriate medications. These included limited awareness, low priority, and uncertainty about the consequences.

One clinical specialist stated: "I don't think it [discontinuation] is always looked into…. Speaking for myself, you understand, I do think it should be. Now that I've been asked to collaborate in the study, well, you start thinking about it."

Another concern physicians mentioned was that by discussing discontinuation of medication, patients will be confronted with their impending death and then may not think that they are receiving optimal medical care.

The authors also point out that when physicians do discuss discontinuing medications, they tend to focus on the inappropriateness of continuing these medication instead of focusing on the advantages of stopping them.

In response to that point, one clinical specialist emphasized that it can be uncomfortable for the physician to have that discussion. He stated: "Yes, it sometimes happens that they're still taking statins and certain medications that may make you wonder, 'Is it any use continuing with those?' But, on the other hand, as a doctor it's sometimes confrontational to say, 'Right, you'll never get well again.' You often also have to say, 'We've run out of treatment options.' Bad news, I must say.… I personally find it sometimes difficult to say, 'Oh, well, you don't need this statin anymore either.'"

The authors note that there are "explicit reasons and implicit factors" that contribute to the current physician practice of not discussing the discontinuation of medication.

"Limited awareness seems to be an important factor," they write. "A way to decrease the use of potentially inappropriate medications may therefore lie in raising physicians' consciousness on this topic."

The physicians interviewed also mentioned that they were concerned about the reactions of patients and relatives, "although individuals with a limited life expectancy and their relatives might be more willing to discontinue PIMs [potentially inappropriate medications]+ than their attending physicians believe," the authors add.

The study was funded by a grant from ZonMw. The authors have disclosed no relative financial relationships.

J Am Geriatr Soc. Published online October 17, 2016. Abstract

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