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Continuation of non-essential medications in actively dying hospitalised patients
  1. Beverly Rosa Williams1,2,
  2. F Amos Bailey1,3,
  3. Elizabeth Kvale1,2,
  4. Neal Steil1,4,
  5. Patricia S Goode1,2,
  6. Richard E Kennedy2 and
  7. Kathryn L Burgio1,2
  1. 1 Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, Alabama, USA
  2. 2 Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
  3. 3 Department of Medicine, Denver Health Medical Center, University of Colorado, Denver, Colorado, USA
  4. 4 Palliative Care Section, Birmingham VA Medical Center, Birmingham, Alabama, USA
  1. Correspondence to Dr Kathryn L Burgio, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC) Birmingham VA Medical Center, Birmingham, Alabama 35233, USA; kburgio{at}uabmc.edu

Abstract

Objective The objective of this analysis was to examine the use of 11 non-essential medications in actively dying patients.

Methods This was a planned secondary analysis of data from the Best Practices for End-of-Life Care for Our Nation’s Veterans trial, a multicentre implementation trial of an intervention to improve processes of end-of-life care in inpatient settings. Supported with an electronic comfort care decision support tool, intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients/families and implement best practices of traditionally home-based hospice care. Data on medication use before and after intervention were derived from electronic medical records of 5476 deceased veterans.

Results Five non-essential medications, clopidogrel, donepezil, glyburide, metformin and propoxyphene, were ordered in less than 5% of cases. More common were orders for simvastatin (15.8%/15.1%), calcium tablets (8.4%/7.9%), multivitamins (11.6%/10.8%), ferrous sulfate (9.1%/7.6%), diphenhydramine (7.2%/5.1%) and subcutaneous heparin (29.9%/27.5%). Significant decreases were found for donepezil (2.5%/1.3%; p=0.001), propoxyphene (0.8%/0.1%; p=0.001), metformin (0.8%/0.3%; p=0.007) and multivitamins (11.6%/10.8%; p=0.01). Orders for one or more non-essential medications were less likely to occur in association with palliative care consultation (adjusted OR (AOR)=0.64, p<0.001), do-not-resuscitate orders (AOR=0.66, p=0.001) and orders for death rattle medication (AOR=0.35, p<0.001). Patients who died in an intensive care unit were more likely to receive a non-essential medication (AOR=1.60, p=0.009), as were older patients (AOR=1.12 per 10 years, p=0.002).

Conclusions Non-essential medications continue to be administered to actively dying patients. Discontinuation of these medications may be facilitated by interventions that enhance recognition and consideration of patients’ actively dying status.

  • medications
  • palliative medicine
  • hospice care
  • end-of-life care
  • hospital care
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Footnotes

  • Contributors FAB, KLB and EK conceived and instigated the planned secondary analysis of the BEACON data. BRW, NS and PSG participated in the literature review and led the synthesis and drafting of this manuscript. David T Redden, PhD, Department of Biostatistics, University of Alabama at Birmingham conducted the initial statistical analyses. REK completed the analysis and participated in drafting and revision of the manuscript.

  • Funding This research was funded by a grant from the Veterans Administration Health Services Research & Development (HSR&D) Program, ‘Impact of An Intervention to Improve Care at Life’s End in VA Medical Centers – BEACON’. IIR 03-126. The sponsor had no role in the study design; in the collection, analysis and interpretation of the data; in the writing of the report; and in the decision to submit the paper for publication.

  • Competing interests None declared.

  • Ethics approval Birmingham VA Medical Center Institutional Review Board for Human Use.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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