DEPRESCRIBING IN HOSPICE
Every hospice patient requires palliative care, which is the aggressive management of symptoms to keep our patients symptom-free and comfortable as they transition out of this world. Polypharmacy is the simultaneous use of multiple medications to manage the health of a patient. A similar complaint I hear from nurses and other healthcare providers, after listening to some of them, is how difficult it is sometimes to convince the patients’ caregivers about the importance of medication deprescribing. To the defense of these caregivers, it can be extremely difficult to accept the reality of what is happening to a loved one. Deprescribing a medication that has shown positive effects over the years may be met with instant remonstrance from loved ones and caregivers who are used to the benefits these medications provided before being in hospice care.
The extremely low degree of health literacy in our community is the big barrier preventing us from achieving this goal of deprescribing. Coming up with a way to educate the caregivers and have them see things from a healthcare professional's point of view, instead of just telling them what you intend to do may be critical in achieving this goal. In other words, as healthcare providers, we should find a way to bring them (the caregivers) along with the plan of care. This can take all disciplines, including pharmacists so that the patients themselves and their caregivers can understand the reason behind our decisions.
Understanding the various disease states, how they manifest, and how they affect the patient can be of help to the patient and his/her caregivers in understanding the reason behind the concept of deprescribing. There are disease states that do not show immediate symptoms or make a patient uncomfortable when medications are not administered. In hospice patients who are at the end of their lives, deprescribing such medications may provide comfort by decreasing pill burden and reducing side effects. Educating patients and caregivers on how these diseases manifest may help them see the need to consider removing these medications from the patient’s med list, thus leaving the most necessary medications that may bring the patient some comfort (Such as pain meds) in their last days of being alive. The following are a few examples.
“Understanding the various disease states, how they manifest, and how they affect the patient can be of help to the patient and his/her caregivers in understanding the reason behind the concept of deprescribing.”
— Dr. Fidelis Ariguzo
Hypertension: Hypertension as a disease state does not produce an immediate symptom when medications are discontinued, except in the case of abrupt discontinuation of a medication that requires tapering down. Management of hypertension also requires the addition of complementary medications such as aspirin to prevent stroke and subsequent organ damage. Proper discontinuation of anti-hypertensive in our hospice patient population will not only eliminate one medication, but there is a possibility that a handful of medications will be eliminated, reducing pill burden, side effects, and keep the patient comfortable.
Dyslipidemia. Just like hypertension, dyslipidemia as a disease state does not present with immediate symptoms when the medications used to manage it are properly discontinued. This disease state is managed with more than one medication to prevent Atherosclerotic cardiovascular diseases. Deprescribing medications used to manage dyslipidemia in this patient population will eliminate a handful of medications from the patient’s list, reduce pill burden, reduce side effects, and keep the patient comfortable.
Supplements: Supplements are necessary to replenish the body’s nutrients, electrolytes, and vitamins. How necessary are tablet supplements at the end of life? Some supplements in tablet forms such as calcium present in huge tablets that may be uncomfortable for the patient to swallow. Knowing which supplement to eliminate may be vital and will reduce pill burden. Educating the caregivers on the physical mechanism of these supplements will enhance their understanding of the reason why it is necessary to eliminate some of them from the patient’s medication list, especially at the end of life.
Tapering down: If we apply this method and find it successful, it is recommended that you talk to the assigned pharmacist before you discontinue these medications. Some medications required tapering down, and this is the best way to prevent rebound symptoms. DO NOT abruptly stop any medication from the medication list without consulting a pharmacist to know if it requires tapering down.
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Fidelis Ifeanyi Ariguzo, PharmD, RPh
PDC Rx