Sunday, June 22, 2008

Polypharmacy & the Meaning of Palliative Care

JAGS has a paper on polypharmacy/inappropriate medication use in patients with dementia receiving palliative care. More or less it's based on a consensus project involving geriatricians asking them what drugs are appropriate or not for patients with severe dementia receiving palliative care. That list was then applied to 30 some patients residing in long term care facilities and it was found that nearly a third of them were receiving at least one 'never use' drug. What is interesting to me is the actual list of drugs and what categories they were placed in via the consensus process.

First, statins and dementia meds (acetylcholinesterase inhibitors, etc.) were on the 'never use' list, along with chemotherapy. While I'm all for not using these agents in patients with severe dementia this very much implies an either/or model of palliative care being employed by these clinicians (as opposed to a concurrent care model; i.e. patients receiving palliative care means the patients are only receiving palliative care, so to speak).

Next, opioids ('narcotics') were on the 'always appropriate' list which is the first time I've seen such a listing for them on any sort of geriatric drug profile.

Last, and most interesting, were the drugs for which there was no consensus: the panel was too divided about their use. These included aspirin, muscle relaxants, 'sedatives and hypnotics,' and CNS stimulants. Clearly clinicians are divided over the use of these drug classes. Myself, looking over the list, found myself going "meh," or "no way" to a substantial number of the drug classifications (the above 4 for me would be rare, rare, sometimes, sometimes) . All of this I think bespeaks how idiosyncratic these decisions can be: the differences across clinicians as to what constitutes a worthless treatment, what is considered harmful or neutral (statin vs. aspirin - aspirin vs. clopidogrel [which was on the never use]), etc. Antiestrogens were on the never appropriate list (although they can have some analgesic/palliative benefit in breast cancer); they would have made my rarely appropriate list.

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