Deciding Hospice Appropriate Medications
Is this prescription expensive? Is this a medication that is covered by hospice? Is this drug right for a hospice patient?
These are questions that run through a nurse’s head when deciding and ordering medications for their hospice patients. In order to understand how to make these decisions, there are some key objectives that need to be discussed. Such objectives include the concept of polypharmacy, the ability to identify necessary and unnecessary medications in the hospice setting, and the ability to recognize the various pharmacologic classes as well as their possible alternative therapies, if any.
First, let’s understand Polypharmacy. Polypharmacy is described as the use of multiple medications, which typically ranges anywhere from 5-10 prescriptions. This is particularly dangerous in the hospice population, as multiple symptoms are easily exacerbated due to decreased nutrition, hydration, immunity, and other factors. The geriatric population in hospice is at an even greater risk due to decreased metabolic clearance and tolerance. Get this - in a sample of Medicare beneficiaries who were discharged from an acute hospitalization and placed in a skilled nursing facility, the patients were prescribed an average of 14 medications! One-third of which had side effects that could exacerbate underlying geriatric syndromes and symptoms (Saraff et al., 2016). As you may assume, this is a problem and leads to a prescribing cascade over time. The cascade occurs when medications are prescribed for symptoms → these medications create additional side effects → prescribe additional medications to assist with the new side effects → each medication starts to counteract or fight another medication → more meds, more symptoms, more problems → we get nowhere and end up wasting precious end-of-life time that should be spent palliating the symptoms to begin with! (Soap box…sorry)
When prescribing medications, there is a lot to consider and there are specific questions to be asked in the process of deciding appropriate hospice coverage.
Some of these questions being:
• Are antihypertensives still appropriate for patient now that he/she is bed bound or no longer eating/drinking?
• Are insulin or antidiabetic medications necessary for the patient who is no longer eating and drinking on a routine basis?
• For the patient who is a fall risk, should we continue anticoagulants?
• When patient is having increasing difficulty with swallowing, should oral medications be continued? Plan to change to other route for those medications still necessary (pain, anti-nausea, anti-anxiety, etc.)
• Is patient currently receiving duplicate therapy? (i.e. receiving >/2 opioids, anxiolytics, laxatives, etc.)
Now that we understand Polypharmacy and the things to consider when deciding hospice coverage, let’s learn about the 4 classes of medication. Each medication prescribed through hospice should fall under the following classes:
1. Medications that should always be continued, such as opioid analgesic for metastatic pain.
2. Medications that should only be continued until a well-defined time, such as stopping insulin or diabetic medications when intake has decreased and/or NPO due to dysphagia.
3. Medications that need to be discontinued because there is no longer an indication for patient to continue receiving medication. (i.e. prophylactic medications, multiple opioids or benzos, statins or other medications that are no longer advantageous for short-term).
4. Medications that now pose a greater risk or burden to patient, such as anticoagulants for the high fall risk patient. (Cote & Correoso-Thomas, 2012)
It can even be broken down into simpler factors like:
• Risk versus Benefit…(i.e. boutique anticoagulants)
o Is the patient living alone and at risk for falls? Previous history of falls? If they’ve had a stroke, how long ago?
• Expected time that patient might have left – based on clinical judgement, Karnofsky score, and what the patient says.
o Will the medication, if new, even have time to take effect?
• Pill burden
o Is the patient already nearly unable to eat, yet we have 5+ pills on the MAR to be given every few hours…if so, which ones are actually necessary – I’ll give you a hit: ONLY THE ONES THAT ARE ACTUALLY OFFERING RELIEF AND PALLIATION TO THE PATIENT.
In conclusion, always think about where the patient is in this stage of his or her life and what would be best. Could it be a “less is more” type situation…?
Jaymie Wilson, APRN-CNP, ACHPN
Cote, T. & Correoso-Thomas, L. (2012). The hospice medical director manual (2nd ed). Chicago, IL: American Academy of Hospice and Palliative Medicine.
Saraff, A., Petersen, A., Simmons, S., Schnelle, J., Bell, S., Kripalani, S…Vasilevskis, E. (2016, June 3). Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities. J Hosp Med, 11(10), 694.