Saturday, January 16, 2016

Medication Discontinuation in Hospice and Palliative Medicine

by Nrupen Bhavsar, Arif Kamal, Donald H. Taylor, Jr.

As a health services and policy research group, we have been looking at a lot of data related to how we deliver care to patients near the end of life. An intriguing area of study is the burden of medications that patients are prescribed when time is short. Here are some data about medication use in the elderly that might be known to many of you but were eye-opening for us:

  • 13% of the US population is over the age of 65 but account for 30% of all prescription medication.
  • Medicare expenditures for end of life care are approximately $150 billion annually, with much of these costs attributable to medication related to supportive care, comorbid conditions, and disease prevention.
  • 61% of older patients under the care of a physician take at least 1 prescription medication; the majority of these patients are taking 3-5 medications. This excludes over the counter medications.
  • A recent palliative care study showed the average number of medications prescribed to patients with a year or less of prognosis is around 12
  • Statins are used in almost 50% of elderly patients.
  • 50% of physicians continue statins for primary prevention until patient death.

However, recent evidence suggests that “statins” (e.g. atorvastatin, simvastatin; medications used to control LDL cholesterol) may not be appropriate in patients with end-stage non-cardiovascular illness. In the Statin Discontinuation Study, investigators from the Palliative Care Research Cooperative (PCRC) reported no survival decrement and improved quality of life in patients whose statin was discontinued when estimated prognosis was 12 months or less. However, the most recent guidelines update from the American College of Cardiology and American Heart Association (ACC/AHA) expanded the indication for statin therapy to prevent cardiovascular disease to an estimated 13 million additional adults. Importantly, the guidelines did not address the appropriateness in patients who have a limited prognosis but are not receiving active end of life care. Prognosis is not a component of their calculator; it is left to clinician judgment how to manage medications not directly related to an active quality of life issue, like pain or nausea. There is similar uncertainty in the appropriate use of other commonly used medications. Research that investigates the appropriateness of real world medication use in patients with life limiting illness may reduce unnecessary spending while improving the quality of care.

We need better information on medication management in patients with limited life expectancy. This week, the American Academy of Hospice and Palliative Medicine (AAHPM) will send a survey to their members on our behalf that aims to understand clinician attitudes and practices regarding counseling patients in palliative care/hospice about medication discontinuation.

Key questions that remain unanswered include:
  1. When should we be engaging patients in discussions about medication discontinuation? Is this about a certain prognosis, functional status, or some other estimation of risks from polypharmacy?
  2. Are there barriers that prevent discussions about medication discontinuation? Are these related to our own practices, working with other clinicians, or patient/family factors?
  3. Whose responsibility is it to manage medications in end of life patients? The palliative care specialist? The primary care provider? The non-palliative care specialists (e.g., cardiologist, nephrologist, etc.)?
There are no easy answers to these questions and we welcome a robust discussion about this.

We encourage you to complete the survey so we can better understand how best to counsel patients about medication discontinuation.

Editor note: I took the survey and it takes less than 10 minutes. - Sinclair

Pallimed Disclaimer on Surveys and Research: Pallimed occasionally publishes opportunities for our readers to participate in research. All surveys are reviewed prior to publication here. We will only do this sporadically. We do not recieve any compensation for publication. If you are interested in collaborating with Pallimed for research, please contact

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