deprescribing at end of life

My pen poised over the drug chart, I hesitate.

Mr Jones* is a 58-year-old patient that my consultation palliative care team is seeing while he’s in hospital with complications of chemotherapy for advanced lung cancer. I am reviewing his discharge medications before he returns home to the care of the community palliative care team.

He is a very optimistic person, not keen to discuss the possibility of his cancer not getting better. An overweight hypertensive smoker, he’s on a full hand of antihypertensives, anti cholesterol medications, vitamin D supplements, a multi-vitamin, and antiplatelet therapy.

His prognosis is likely less than a year in my mind. Does he need all these medications?

A retrospective cohort study by Todd et al examined this question in groups of people with advanced lung cancer in the United States and the UK. The patients had died and been admitted to hospital then discharged at least once in their last 6 months of life. 

They report that comorbidities are common in the people suffering from lung cancer and that the people often take various medications to prevent future complications, even if those complications are quite unlikely to occur as the person is more likely to die sooner from their cancer. The reason to be concerned about this is that those medications can cause side effects, interact with other medications, cause a “pill burden” where the person is sick of taking so many medications, and also the financial cost of the medications to the person and society.

Because patients with advanced cancer often need to be admitted to hospital in their last year of life, a hospital admission provides a chance to review and rationalise their medications.

The study found that UK patients who were admitted to hospital in their last 6 months of life had an average of 1.9 preventive medications on admission and 1.7 on discharge. US patients took more, an average 2.6 preventive medications on admission and 1.9 on discharge. Polypharmacy, defined as >= 5 medications, was also common at both sites (observed in 81.6% and 93.7% of individuals admitted to hospital at UK and US sites, respectively), with the total number of medications increasing after each hospital admission. 

The authors noted the likely positive influences of palliative consultation services and consultations from a clinical pharmacist as being important in reducing unnecessary preventive medications at the end of life.

Chart in hand, I knock on Mr Jones’ hospital room door.

*not his real name

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