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Decision Making About Change of Medication for Comorbid Disease at the End of Life: An Integrative Review

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Abstract

The main goal of palliative care is to improve quality of life by treating symptoms in patients with life-threatening illnesses. Most patients suffer from more than five severe comorbidities in the last 6 months of life. However, for patients receiving palliative care, interventions to prevent possible long-term complications of these comorbidities are no longer the primary aim of care. This paper aimed to review the literature regarding decision making about medication for comorbid disease at the end of life, defined as a life expectancy <3 months, and to formulate preliminary recommendations based on the existing literature. An integrative review approach was used. We searched the MEDLINE, EMBASE, and CINAHL databases. Papers were included if they had been published in the English language between 1 January 1995 and 31 December 2013, with an abstract. Additional studies were identified by searching bibliographies. Factors to consider when systematically reviewing medications are the goals of care, remaining life expectancy, treatment targets, time until benefit, number needed to treat, number needed to harm, and adverse drug reactions. Existing research focuses particularly on the use of certain drug classes during end-of-life care, including statins, antihypertensive agents, anticoagulants, antihyperglycaemic agents and antibiotics. Based on the results of this review, we made preliminary recommendations for these medication groups. Medication that does not benefit the patient in any way should be avoided. The aim of medication at the end of life should be symptom control. There is a need for prospective trials to give further insight into the decision-making process of medication management at the end of life.

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References

  1. Koh NY, Koo WH. Polypharmacy in palliative care: can it be reduced? Singapore Med J. 2002;43(6):279–83.

    CAS  PubMed  Google Scholar 

  2. Sepulveda C, Marlin A, Yoshida T, et al. Palliative care: the World Health Organization’s global perspective. J Pain Symptom Manag. 2002;24(2):91–6.

    Article  Google Scholar 

  3. Hui D, Mori M, Parsons HA, et al. The lack of standard definitions in the supportive and palliative oncology literature. J Pain Symptom Manag. 2012;43(3):582–92.

    Article  Google Scholar 

  4. Van Mechelen W, Aertgeerts B, De Ceulaer K, et al. Defining the palliative care patient: a systematic review. Palliat Med. 2013;27(3):197–208.

    Article  PubMed  Google Scholar 

  5. Unit EI, Britain G. The quality of death: ranking end-of-life care across the world. Economist Intelligence Unit; 2010.

  6. Kierner KA, Gartner V, Schwarz M, et al. Use of thromboprophylaxis in palliative care patients: a survey among experts in palliative care, oncology, intensive care, and anticoagulation. Am J Hosp Palliat Care. 2008;25(2):127–31.

    Article  PubMed  Google Scholar 

  7. Currow DC, Stevenson JP, Abernethy AP, et al. Prescribing in palliative care as death approaches. J Am Geriatr Soc. 2007;55(4):590–5.

    Article  PubMed  Google Scholar 

  8. Nauck F, Ostgathe C, Klaschik E, et al. Drugs in palliative care: results from a representative survey in Germany. Palliat Med. 2004;18(2):100–7.

    Article  PubMed  Google Scholar 

  9. Sokol KC, Knudsen JF, Li MM. Polypharmacy in older oncology patients and the need for an interdisciplinary approach to side-effect management. J Clin Pharm Ther. 2007;32(2):169–75.

    Article  CAS  PubMed  Google Scholar 

  10. Riechelmann RP, Tannock IF, Wang L, et al. Potential drug interactions and duplicate prescriptions among cancer patients. J Natl Cancer Inst. 2007;99(8):592–600.

    Article  PubMed  Google Scholar 

  11. Holmes HM. Rational prescribing for patients with a reduced life expectancy. Clin Pharmacol Ther. 2009;85(1):103–7.

    Article  CAS  PubMed  Google Scholar 

  12. Zeppetella G. How do terminally ill patients at home take their medication? Palliat Med. 1999;13(6):469–75.

    Article  CAS  PubMed  Google Scholar 

  13. Fede A, Miranda M, Antonangelo D, et al. Use of unnecessary medications by patients with advanced cancer: cross-sectional survey. Support Care Cancer. 2011;19(9):1313–8.

    Article  PubMed  Google Scholar 

  14. Riechelmann RP, Krzyzanowska MK, Zimmermann C. Futile medication use in terminally ill cancer patients. Support Care Cancer. 2009;17(6):745–8.

    Article  PubMed  Google Scholar 

  15. Stevenson J, Abernethy AP, Miller C, et al. Managing comorbidities in patients at the end of life. BMJ. 2004;329(7471):909–12.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–53.

    Article  PubMed  Google Scholar 

  17. Disler RT, Currow DC, Phillips JL, et al. Interventions to support a palliative care approach in patients with chronic obstructive pulmonary disease: an integrative review. Int J Nurs Stud. 2012;49(11):1443–58.

    Article  PubMed  Google Scholar 

  18. Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6):605–9.

    Article  PubMed  Google Scholar 

  19. Currow DC, Abernethy AP. Frameworks for approaching prescribing at the end of life. Arch Intern Med. 2006;166(21):2404.

    PubMed  Google Scholar 

  20. Cruz-Jentoft AJ, Boland B, Rexach L. Drug therapy optimization at the end of life. Drugs Aging. 2012;29(6):511–21.

    Article  PubMed  Google Scholar 

  21. Fins JJ, Miller FG, Acres CA, et al. End-of-life decision-making in the hospital: current practice and future prospects. J Pain Symptom Manag. 1999;17(1):6–15.

    Article  CAS  Google Scholar 

  22. McLean S, Sheehy-Skeffington B, O’Leary N, et al. Pharmacological management of co-morbid conditions at the end of life: is less more? Ir J Med Sci. 2012;182(1):107–12.

    Article  PubMed  Google Scholar 

  23. O’Mahony D, O’Connor MN. Pharmacotherapy at the end-of-life. Age Ageing. 2011;40(4):419–22.

    Article  PubMed  Google Scholar 

  24. Parsons C, Hughes CM, Passmore AP, et al. Withholding, discontinuing and withdrawing medications in dementia patients at the end of life: a neglected problem in the disadvantaged dying? Drugs Aging. 2010;27(6):435–49.

    Article  PubMed  Google Scholar 

  25. Riechelmann RP, Moreira F, Smaletz O, et al. Potential for drug interactions in hospitalized cancer patients. Cancer Chemother Pharmacol. 2005;56(3):286–90.

    Article  PubMed  Google Scholar 

  26. Stevenson JP, Currow DC, Abernethy AP. Frameworks for prescribing in comorbid illness. J Pain Symptom Manag. 2007;34(2):117–8.

    Article  Google Scholar 

  27. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24.

    Article  PubMed  Google Scholar 

  28. Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc. 2008;56(10):1946–52.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing. 2008;37(6):673–9.

    Article  PubMed  Google Scholar 

  30. Spinewine A, Dumont C, Mallet L, et al. Medication appropriateness index: reliability and recommendations for future use. J Am Geriatr Soc. 2006;54(4):720–2.

    Article  PubMed  Google Scholar 

  31. Tjia J, Velten SJ, Parsons C, et al. Studies to reduce unnecessary medication use in frail older adults: a systematic review. Drugs Aging. 2013;30(5):285–307.

    Article  PubMed  Google Scholar 

  32. Suhrie EM, Hanlon JT, Jaffe EJ, et al. Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing. Am J Geriatr Pharmacother. 2009;7(1):20–5.

    Article  PubMed  Google Scholar 

  33. Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648–54.

    Article  PubMed  Google Scholar 

  34. Garfinkel D, Zur-Gil S, Ben-Israel J. The war against polypharmacy: a new cost-effective geriatric-palliative approach for improving drug therapy in disabled elderly people. Isr Med Assoc J. 2007;9(6):430–4.

    PubMed  Google Scholar 

  35. Brandt NJ, Stefanacci RG. Discontinuation of unnecessary medications in older adults. Consult Pharm. 2011;26(11):845–54.

    Article  PubMed  Google Scholar 

  36. Silveira MJ, Kazanis AS, Shevrin MP. Statins in the last six months of life: a recognizable, life-limiting condition does not decrease their use. J Palliat Med. 2008;11(5):685–93.

    Article  PubMed  Google Scholar 

  37. Vollrath AM, Sinclair C, Hallenbeck J. Discontinuing cardiovascular medications at the end of life: lipid-lowering agents. J Palliat Med. 2005;8(4):876–81.

    Article  PubMed  Google Scholar 

  38. Bayliss EA, Bronsert MR, Reifler LM, et al. Statin prescribing patterns in a cohort of cancer patients with poor prognosis. J Palliat Med. 2013;16(4):412–8.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Hippisley-Cox J, Coupland C. Unintended effects of statins in men and women in England and Wales: population based cohort study using the QResearch database. BMJ. 2010;340:c2197.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Bottorff MB. Statin safety and drug interactions: clinical implications. Am J Cardiol. 2006;97(8A):27C–31C.

    Article  CAS  PubMed  Google Scholar 

  41. Davis GF. Discontinuing lipid-lowering agents. J Palliat Med. 2006;9(3):619 (author reply 21-2).

    Article  PubMed  Google Scholar 

  42. Vandenhaute V. Palliative care and type II diabetes: a need for new guidelines? Am J Hosp Palliat Care. 2010;27(7):444–5.

    Article  PubMed  Google Scholar 

  43. Ford-Dunn S, Smith A, Quin J. Management of diabetes during the last days of life: attitudes of consultant diabetologists and consultant palliative care physicians in the UK. Palliat Med. 2006;20(3):197–203.

    Article  CAS  PubMed  Google Scholar 

  44. Angelo M, Ruchalski C, Sproge BJ. An approach to diabetes mellitus in hospice and palliative medicine. J Palliat Med. 2011;14(1):83–7.

    Article  PubMed  Google Scholar 

  45. King EJ, Haboubi H, Evans D, et al. The management of diabetes in terminal illness related to cancer. QJM. 2012;105(1):3–9.

    Article  CAS  PubMed  Google Scholar 

  46. Tice MA. Diabetes management at the end of life: transitioning from tight glycemic control to comfort. Home Healthc Nurse. 2006;24(5):290–3.

    Article  PubMed  Google Scholar 

  47. Holmes HM, Bain KT, Zalpour A, et al. Predictors of anticoagulation in hospice patients with lung cancer. Cancer. 2010;116(20):4817–24.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Legault S, Tierney S, Senecal I, et al. Evaluation of a thromboprophylaxis quality improvement project in a palliative care unit. J Pain Symptom Manag. 2011;41(3):503–10.

    Article  Google Scholar 

  49. Spiess JL. Can I stop the warfarin? A review of the risks and benefits of discontinuing anticoagulation. J Palliat Med. 2009;12(1):83–7.

    Article  PubMed  Google Scholar 

  50. Kakkar AK, Levine MN, Kadziola Z, et al. Low molecular weight heparin, therapy with dalteparin, and survival in advanced cancer: the fragmin advanced malignancy outcome study (FAMOUS). J Clin Oncol. 2004;22(10):1944–8.

    Article  CAS  PubMed  Google Scholar 

  51. Chambers JC. Prophylactic heparin in palliative care: … to a challenging idea. BMJ. 2006;332(7543):729.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Gillon S, Noble S, Ward J, et al. Primary thromboprophylaxis for hospice inpatients: who needs it? Palliat Med. 2011;25(7):701–5.

    Article  PubMed  Google Scholar 

  53. Soto-Cardenas MJ, Pelayo-Garcia G, Rodriguez-Camacho A, et al. Venous thromboembolism in patients with advanced cancer under palliative care: additional risk factors, primary/secondary prophylaxis and complications observed under normal clinical practice. Palliat Med. 2008;22(8):965–8.

    Article  CAS  PubMed  Google Scholar 

  54. Johnson MJ. Problems of anticoagulation within a palliative care setting: an audit of hospice patients taking warfarin. Palliat Med. 1997;11(4):306–12.

    Article  CAS  PubMed  Google Scholar 

  55. Johnson MJ, Sherry K. How do palliative physicians manage venous thromboembolism? Palliat Med. 1997;11(6):462–8.

    Article  CAS  PubMed  Google Scholar 

  56. Kirkova J, Fainsinger RL. Thrombosis and anticoagulation in palliative care: an evolving clinical challenge. J Palliat Care. 2004;20(2):101–4.

    PubMed  Google Scholar 

  57. McLean S, Ryan K, O’Donnell JS. Primary thromboprophylaxis in the palliative care setting: a qualitative systematic review. Palliat Med. 2010;24(4):386–95.

    Article  PubMed  Google Scholar 

  58. Noble S. Management of venous thromboembolism in the palliative care setting. Int J Palliat Nurs. 2007;13(12):574–9.

    Article  PubMed  Google Scholar 

  59. Noble SI, Nelson A, Finlay IG. Factors influencing hospice thromboprophylaxis policy: a qualitative study. Palliat Med. 2008;22(7):808–13.

    Article  CAS  PubMed  Google Scholar 

  60. Noble SI, Hood K, Finlay IG. The use of long-term low-molecular weight heparin for the treatment of venous thromboembolism in palliative care patients with advanced cancer: a case series of sixty two patients. Palliat Med. 2007;21(6):473–6.

    Article  CAS  PubMed  Google Scholar 

  61. Noble S. The challenges of managing cancer related venous thromboembolism in the palliative care setting. Postgrad Med J. 2007;83(985):671–4.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Tran QN. Role of palliative low-molecular-weight heparin for treating venous thromboembolism in patients with advanced cancer. Am J Hosp Palliat Care. 2010;27(6):416–9.

    Article  PubMed  Google Scholar 

  63. Weber C, Merminod T, Herrmann FR, et al. Prophylactic anti-coagulation in cancer palliative care: a prospective randomised study. Support Care Cancer. 2008;16(7):847–52.

    Article  PubMed  Google Scholar 

  64. Stiel S, Krumm N, Pestinger M, et al. Antibiotics in palliative medicine: results from a prospective epidemiological investigation from the HOPE survey. Support Care Cancer. 2012;20(2):325–33.

    Article  PubMed  Google Scholar 

  65. Enck RE. Antibiotic use in end-of-life care: a soft line? Am J Hosp Palliat Care. 2010;27(4):237–8.

    Article  PubMed  Google Scholar 

  66. Oh DY, Kim JH, Kim DW, et al. Antibiotic use during the last days of life in cancer patients. Eur J Cancer Care (Engl). 2006;15(1):74–9.

    Article  CAS  Google Scholar 

  67. Lam PT, Chan KS, Tse CY, et al. Retrospective analysis of antibiotic use and survival in advanced cancer patients with infections. J Pain Symptom Manag. 2005;30(6):536–43.

    Article  Google Scholar 

  68. Chun ED, Rodgers PE, Vitale CA, et al. Antimicrobial use among patients receiving palliative care consultation. Am J Hosp Palliat Care. 2010;27(4):261–5.

    Article  PubMed  Google Scholar 

  69. White PH, Kuhlenschmidt HL, Vancura BG, et al. Antimicrobial use in patients with advanced cancer receiving hospice care. J Pain Symptom Manag. 2003;25(5):438–43.

    Article  Google Scholar 

  70. Abduh Al-Shaqi M, Alami AH, Zahrani AS, et al. The pattern of antimicrobial use for palliative care in-patients during the last week of life. Am J Hosp Palliat Care. 2012;29(1):60–3.

    Article  PubMed  Google Scholar 

  71. Chen LK, Chou YC, Hsu PS, et al. Antibiotic prescription for fever episodes in hospice patients. Support Care Cancer. 2002;10(7):538–41.

    Article  PubMed  Google Scholar 

  72. Mirhosseini M, Oneschuk D, Hunter B, et al. The role of antibiotics in the management of infection-related symptoms in advanced cancer patients. J Palliat Care. 2006;22(2):69–74.

    PubMed  Google Scholar 

  73. Oneschuk D, Fainsinger R, Demoissac D. Antibiotic use in the last week of life in three different palliative care settings. J Palliat Care. 2002;18(1):25–8.

    PubMed  Google Scholar 

  74. Nagy-Agren S, Haley H. Management of infections in palliative care patients with advanced cancer. J Pain Symptom Manag. 2002;24(1):64–70.

    Article  Google Scholar 

  75. Pereira J, Watanabe S, Wolch G. A retrospective review of the frequency of infections and patterns of antibiotic utilization on a palliative care unit. J Pain Symptom Manag. 1998;16(6):374–81.

    Article  CAS  Google Scholar 

  76. Vitetta L, Kenner D, Sali A. Bacterial infections in terminally ill hospice patients. J Pain Symptom Manag. 2000;20(5):326–34.

    Article  CAS  Google Scholar 

  77. Thompson AJ, Silveira MJ, Vitale CA, et al. Antimicrobial use at the end of life among hospitalized patients with advanced cancer. Am J Hosp Palliat Care. 2012;29(8):599–603.

    Article  PubMed  Google Scholar 

  78. Ballentine NH. Polypharmacy in the elderly: maximizing benefit, minimizing harm. Crit Care Nurs Q. 2008;31(1):40–5.

    Article  PubMed  Google Scholar 

  79. Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med. 1995;333(20):1301–7.

    Article  CAS  PubMed  Google Scholar 

  80. Noble SI, Nelson A, Turner C, et al. Acceptability of low molecular weight heparin thromboprophylaxis for inpatients receiving palliative care: qualitative study. BMJ. 2006;332(7541):577–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  81. Clayton J, Fardell B, Hutton-Potts J, et al. Parenteral antibiotics in a palliative care unit: prospective analysis of current practice. Palliat Med. 2003;17(1):44–8.

    Article  PubMed  Google Scholar 

  82. Cannon KT, Choi MM, Zuniga MA. Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis. Am J Geriatr Pharmacother. 2006;4(2):134–43.

    Article  PubMed  Google Scholar 

  83. Nguyen JK, Fouts MM, Kotabe SE, et al. Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents. Am J Geriatr Pharmacother. 2006;4(1):36–41.

    Article  PubMed  Google Scholar 

  84. Zarowitz BJ, Stebelsky LA, Muma BK, et al. Reduction of high-risk polypharmacy drug combinations in patients in a managed care setting. Pharmacotherapy. 2005;25(11):1636–45.

    Article  PubMed  Google Scholar 

  85. Koopmans RT, Lavrijsen JC, Hoek JF, et al. Dutch elderly care physician: a new generation of nursing home physician specialists. J Am Geriatr Soc. 2010;58(9):1807–9.

    Article  PubMed  Google Scholar 

  86. Di Giulio P, Toscani F, Villani D, et al. Dying with advanced dementia in long-term care geriatric institutions: a retrospective study. J Palliat Med. 2008;11(7):1023–8.

    Article  PubMed  Google Scholar 

  87. Hoek JF, Ribbe MW, Hertogh CM, et al. The role of the specialist physician in nursing homes: the Netherlands’ experience. Int J Geriatr Psychiatry. 2003;18(3):244–9.

    Article  PubMed  Google Scholar 

  88. Arnold EM. The cessation of cancer treatment as a crisis. Soc Work Healthc. 1999;29(2):21–38.

    Article  CAS  Google Scholar 

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Acknowledgments

No sources of funding were used to assist in the preparation of this review. Ronald T.C.M. van Nordennen, Jan Lavrijsen, Kris Vissers and Raymond Koopmans have no potential conflicts of interest that are directly relevant to the content of this review.

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Correspondence to Ronald T. C. M. van Nordennen.

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van Nordennen, R.T.C.M., Lavrijsen, J.C.M., Vissers, K.C.P. et al. Decision Making About Change of Medication for Comorbid Disease at the End of Life: An Integrative Review. Drugs Aging 31, 501–512 (2014). https://doi.org/10.1007/s40266-014-0182-4

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