Study highlights need for appropriate medication discontinuation in hospice care
Patients referred to home hospice care following non-cancer diagnoses had their preventative medications significantly reduced between admission and death, though this did not apply to patients with cancer referred to hospice care, a retrospective study from Singapore showed.
The researchers assessed medication use and discontinuation among 6,158 cancer (50 percent female, median age at death 72 years) and 780 non-cancer (60.3 percent female, median age at death 81 years) patients referred to HCA Hospice Care in Singapore between 2011 and 2015. Medication use was assessed on the day of patients’ admission to hospice care and at death. The most common non-cancer diagnoses warranting hospice referral were genitourinary, respiratory, and circulatory disorders (26.9, 17.1, and 11.7 percent, respectively). Patients with both cancer and non-cancer diagnosis, those who were not prescribed any medications, and those prescribed only as-needed medications were excluded. The OncPal Deprescribing Guideline was used to identify appropriate medication discontinuations.
Patients with non-cancer diagnoses were on more preventative medications at admission than those with a cancer diagnosis (mean, 7.84 vs 5.65). However, patients with a non-cancer diagnoses had their medications significantly reduced between hospice referral and death (mean number of medications at death, 7.07; p<0.05), which was not the case for patients referred following a cancer diagnosis (mean number of medications at death, 5.69; p=0.372). [J Palliat Med 2019;doi:10.1089/jpm.2018.0559]
The most common preventative medications used by cancer and non-cancer patients were senna glycosides (67.7 and 60.9 percent, respectively), lactulose (59.7 and 53.1 percent, respectively), and omeprazole (52.5 and 48.5 percent, respectively). Patients with cancer were more likely to use analgesics than those with non-cancer diagnoses, namely morphine (41.2 percent vs 27.2 percent), fentanyl (33.7 percent vs 22.1 percent), tramadol (18.8 percent vs 6.4 percent), and paracetamol (31.7 percent vs 25.4 percent). Other drugs used more frequently in cancer than non-cancer patients were metoclopramide (33.2 percent vs 15.4 percent), dexamethasone (21.8 percent vs 1.2 percent), gabapentin (17.1 percent vs 7.2 percent), and nystatin (15.9 percent vs 5.3 percent).
Conversely, patients with non-cancer diagnoses were more likely to use furosemide (47.4 percent vs 18.6 percent) and simvastatin (20.9 percent vs 12.9 percent) than those with a cancer diagnosis.
Furosemide, simvastatin, amlodipine, and spironolactone were discontinued in 70.6, 62.4, 68.0, and 65.9 percent of patients, respectively, while omeprazole was discontinued in 45.4 percent of the patients. Of the most common preventative medications used in hospice care (omeprazole, furosemide, and simvastatin), all cases of simvastatin discontinuation were deemed appropriate, as were 85.4 and 89.8 percent of furosemide and omeprazole discontinuations, respectively.
“[W]ith high medication burdens in hospice care, there has been a growing realization among physicians on the importance of deprescribing,” said the researchers. This particularly pertains to medications that may not improve quality of life (eg, potentially inappropriate medications [PIM]), they said.
One such example was omeprazole which was one of the most frequently prescribed medications and was discontinued in less than half the participants. “[T]he current results [suggest] a questionable indication in the use of omeprazole, especially as patients develop swallowing difficulties. This is especially relevant if patients have no medical history of gastrointestinal bleeding, ulcer, and related events,” the researchers said.
Nonetheless, the appropriate discontinuation rates in this study highlight that “steps are currently being taken by our health care team to reduce polypharmacy and PIM use in home hospice settings.”
According to the researchers, the higher rate of analgesics in cancer vs non-cancer patients was expected given that pain and symptom control were the primary reasons for hospice referral in this study. The high use of laxatives was also unsurprising with constipation a common problem at end of life and with opioid use. [J Pain Symptom Manage 1997;14:328-331; Ther Clin Risk Manag 2010;6:77-82]
They also noted that the low use of haloperidol may be due to exclusion of as-needed medications in this study, and as such, may not reflect real-life settings.
“[These results could] allow health care professionals to formulate more informed care plans based on individualized needs of the patients. Regular medication reviews with open communication between prescribers, patients, and caregivers may be beneficial in overcoming the barriers to deprescribing to reduce polypharmacy and PIM use,” the researchers concluded.