Focus on deprescribing
One of the audits collected on our Ashtons Live View system is the number of prescription items for each patient. This information enables us to provide you with comparative data and percentages for our clinical interventions. It is not unusual to count more than twenty items for one patient on a hospice drug chart, although many of these items will be on the PRN pages. We pay great attention to detail with the patient’s response to their medicines, but what are the prompts for reducing the number of items? It can take considerable time to administer medicines when a patient is weak and finding large amounts to swallow challenging. It may be observed but not always reported by the nurses and proposed as an opportunity to rationalise. The patient may ask ‘do I really have to take all these?’ or refuse their medicines selectively or entirely. Making prescribing decisions may sometimes be quite simple – the patient is reported as being constipated, so we write up one or two laxatives. Their pain is showing neuropathic characteristics, so we add in a tricyclic or gabapentinoid and within a few moments, they are being asked to take maybe six additional doses. Should we be looking at which items on a drug chart we can safely remove as carefully and regularly as those we might add? We know that many commonly used medicines have similar side effect profiles, and that additive sedation and anticholinergic effects can add to symptoms and increase the risk of falls. The positive effects need to outweigh the potential negatives, and we should review drug regimens for such risks.
The term ‘polypharmacy’ has become a rather pejorative term and although it is now acknowledged that it is difficult to avoid in symptom control towards the end of life, we still need to consider it.
Prescribing for a person for complex conditions or for multiple conditions in circumstances where medicine use has been optimised and where the medicines are prescribed according to best evidence.
Problematic polypharmacy occurs when multiple medicines are prescribed inappropriately or where the intended benefits from the medicines are not realised.
Medicine rationalisation and deprescribing are now relevant in all areas of therapeutics. NICE guidance suggests regimes for specific diagnoses, but this does not take into account that some people will have several co-morbidities and have multiple drugs prescribed as a result. NICE has now collated resources to guide us in the rationalisation of medicines, acknowledging the potential problems with multi-morbidity and polypharmacy1. The new resource directs to documents including those from the Royal Pharmaceutical Society and the UK national health bodies with titles such as ‘Getting medicines right’. These are generally similar and useful for GPs caring for people with chronic conditions. Tools such as the Beers Criteria2 have been developed to provide very detailed options on the various categories of medicines however, there is a simpler and more appropriate tool for people approaching the end of life. The STOPPFrail tool3 was developed in Sunderland and validated by a study in Ireland4 as an adaptation of the STOPP (Screening Tool of Older Persons Prescriptions), specifically for frail adults with a limited life expectancy. To apply this, the patient must fulfil all these criteria:
- End stage irreversible pathology.
- Poor one-year survival prognosis.
- Severe functional impairment or severe cognitive impairment or both.
- Symptom control is the priority rather than prevention of disease progression.
The first consideration in the STOPPFrail Tool focuses on discontinuing any drug the patient persistently fails to take or tolerate despite adequate explanation and consideration of alternative formulations. The second consideration is – any drug without clear clinical indication. It is concerning that some prescriptions may be on repeat cycles and not reviewed periodically in primary care. There is also understandable reluctance for stopping medicines which have been prescribed by other specialists and the guidance in these tools helps with these decisions.
Of course, there are some conditions where it is essential to continue with the medicines until the last days of life, so we need to refer to specific guidance for Parkinson’s disease and diabetes, for example.
Suggestions start by looking at the drug chart for ‘refusals’ and discussing with the patient why they do not want to take the medicine – perhaps these items can be safely crossed off. Then look at additive side effects and consider whether any causing side effects such as drowsiness or dry mouth could be removed. Discuss the pros and cons of stopping or continuing with the patient.
Look at those medicines which are preventative and consider the benefits of continuing them (see below), but at all times consider the risks and benefits for each individual patient.
Drugs to consider stopping towards the end of life:
- Vitamin / mineral supplements
- Statins – evidence shows they still protect for one year after stopping
- Review anti-hypertensives – may be able to reduce dose or stop
- Aspirin low-dose
- Some inhalers – especially where patients are too weak to use them effectively
- Gastro-protection – maybe steroids have been stopped?
- Oral hypoglycaemics – if the person is no longer eating
- Oral anti-oestrogens/anti-androgens
In any prescribing decision it is important to involve the person who is taking the medicine and this is equally pertinent when it comes to stopping. When a patient has been told they must take a medicine ‘for life’, stopping it can feel dangerous and may also reinforce the fact that they are coming towards the end of their life. However, in practice, many people are relieved to reduce their tablet burden, so it is, as with everything in palliative care, tailored to the patient. One helpful strategy is to suggest a trial of stopping the drug and see what the effects are. If stopping makes a symptom worse, the medicine can be re-started.
If you would like to look at this in more detail, we can now offer training sessions to hospice staff on these topics:
- Polypharmacy and deprescribing towards the end of life.
- Management of Parkinson’s disease towards the end of life.
- Management of diabetes towards the end of life.