Polypharmacy and medication errors on admission to palliative care
Key words: medication errors, palliative care, polypharmacy, referralEditOrial
CC BY-NC-SA 4.0
Polypharmacy and medication errors on admission to palliative care
CC BY-NC-SA 4.0
Introduction: Many patients at the end of their life are treated with multiple medications while some of the drugs may no longer be beneficial and should be reduced.
Objectives: The aim of the study was to assess polypharmacy, overprescribing, and the incidence of presumable pharmacological errors at referral to palliative care.
Patients and methods: Current treatment in consecutive patients was analyzed based on the clinical judgment of a palliative care specialist on the first appointment. The number of drugs/tablets with pharmacotherapy inappropriateness was counted, analyzed, and a new therapy was proposed.
Results: A total of 337 patients were admitted. The median number of drugs/tablets used at referral was 7/9 per day. In patients with short life prognosis, the corresponding numbers were higher (8/10). Polypharmacy was found in 265 patients (78.6%) and at least 1 drug inappropriateness occurred in 238 patients (70.6%). The most frequent error type was lack of necessary concomitant drug. Patients who were bed‑bound (Palliative Performance Scale ≤40 points), with the shortest life expectancy (Gold Standards Framework, D), who died within 2 weeks or were discharged from the hospital and admitted to hospice had more often 1 or more potentially inappropriate medication. The risk of inappropriateness increased with the number of drugs/tablets prescribed by 13.3%/7.4% per drug/tablet. The median number of drugs/tablets decreased on palliative consultation by 1.0/2.0 (P = 0.01/P <0.001, respectively). Subgroups with a higher number of errors had a larger drug reduction.
Conclusions: Polypharmacy and increased risk of drug inappropriateness particularly affect elderly patients referred by hospitals, with poor prognosis, low performance, admitted to in‑patient hospice. Therapy reduction may diminish the risk of therapeutic inappropriateness but requires further education within nonspecialist palliative care.
What's new?
Polypharmacy is found in more than three‑quarters of patients referred to palliative care. Two‑thirds have at least 1 inappropriate medication prescribed, more frequently affecting those with more serious illness and correlating with the number of drugs/tablets received. The most common type of error is unnecessary treatment (eg, proton pump inhibitors and lipid‑lowering drugs), the deficiency of necessary concomitant medication (eg, absence of laxatives in spite of regular opioid use), and insufficient clinical/metabolic monitoring. Clinicians regardless of discipline should have basic knowledge of symptom management and systematically assess patients’ pharmacotherapy. At the end of life, only a few essential drugs are usually needed to maintain quality care. The physicians who are inexperienced in medication management in terminally ill patients should turn to a palliative care specialist for consultation. Reducing drug/tablet intake in these patients may be considered to diminish the risk of therapeutic inappropriateness.
Introduction
In palliative care (PC), it is of paramount importance to continuously ensure the best possible quality of life. In a recent European survey of patients with advanced cancer on opioids, it has been found they were given a mean of 7.8 drugs and more than 1 in 4 patients used 10 or more drugs.1 Every medical intervention in PC, including pharmacotherapy, needs to be assessed according to achievable benefits and possible harms in the light of the expected prognosis. When drugs are no longer beneficial, and especially when they become potentially harmful, it is ethically justified to reduce or stop them. In the last months of life the majority of preventive drugs can be deprescribed, especially as patients may need additional symptom relieving medications.2 This process is, however, difficult because of many barriers, such as the fear of confronting the patient with his or her poor prognosis or concerns over clinical complications.3 Some 20% of drugs in common use in the treatment of elderly patients may be inappropriate, and that ratio increases beyond 30% in aged care facilities.4 In the group of nursing home residents with advanced dementia, more than 1 in 2 patients are administered at least 1 drug whose beneficiary effect is challengeable. Approximately half of hospitalized patients or nursing home residents receive at least 1 unnecessary drug. However, current data from the first palliative appointment in Poland is still lacking. The aim of this study was to assess polypharmacy, overprescribing, and the incidence of presumable pharmacological errors in patients at referral to palliative care.Patients and methodsThe following principles of prescribing in end‑of‑life patients according to the current literature1,5‑9 were applied to the routine clinical practice, starting in June 2016: 1) the aim is to have 1 prescribing physician for 1 patient; 2) the definition of treatment goals is of principal importance; 3) life‑extending drugs within last weeks of life are seldom appropriate; 4) in the case of drugs for primary prevention, the time‑to‑benefit ratio is usually too long; 5) drugs indicated for tertiary prevention require periodic reevaluation; 6) prescribing more than 5 drugs in 1 patient should be avoided; 7) change of 1 drug at 1 time with close monitoring should be preferred; and 8) fewer tablets and doses per day (long acting/drug combination) should be chosen. The checklist comprising potential inappropriateness of pharmacotherapy in the PC setting was also implemented in the hospice (Table 1).5 Table 1. Routinely used checklist of potentially inappropriate medications in hospice careMedicationConsideration for limited benefitCholesterol‑lowering drugs (statins)Time‑to‑benefit usually exceeds life expectancyAspirinFor primary preventionHypotonic drugsIf normotensiveHeparinsFor primary preventionVitamin K antagonistsFor non‑high thromboembolic risk excluding prosthetic heart valveNitrates for stable anginaIneffective in improving quality of lifeProton pump inhibitors in preventionTime‑to‑benefit usually exceeds life expectancyOsteoporosis medicationsExcluding for hypercalcemia in bone metastasisOral hypoglycemic agentsIn type 2 diabetes to reduce mild hyperglycemiaVitamins/minerals/complementary drugsNo evidence of effectiveness In the current cross‑sectional study, we enrolled all consecutive patients admitted to the palliative outpatient clinic (700 consultations per year) and free‑standing, acute (median time of care of 7 days and inpatient mortality rate of 74%), 42‑bed hospice between August 1, 2016 and December 31, 2017. The medications consumed in the last 24 hours (including prescription, over‑the‑counter, and herbal products) were analyzed on the first hospice appointment by 6 palliative medicine specialists with respect to the following subgroup categories: age (0–59, 60–75, and >75 years), prognosis (according to the Gold Standards Framework [GSF]10: A–B, C–D), length of care (died within 0–7, 8–14, 15–30, 31–90, >90 days or discharged), and functional capacity (according to the Palliative Performance Scale [PPS]: 0–40, 50–100). The participating consultants in palliative care were asked to mention, based solely on clinical judgment, all inconsistencies between the patients’ clinical condition, the goals of care, symptoms profile, and the list of drugs taken. Drugs were defined as unnecessary or inappropriate if: a) the time needed to obtain a clinically meaningful benefit was longer than the remaining survival time, b) the therapeutic target did not align with the preferences expressed by the patient regarding the goals of care, or c) the harm caused by the treatment outweighed the expected benefit, especially if the risks arose before the benefit.11 The checklist of potentially inappropriate medications (Table 1) and the commonly known drug–drug interactions1 were also taken into account. During the same appointment, the routinely performed process of therapy adjustment was initiated. The numbers of drugs/tablets used prior to admission were then counted and compared with those prescribed during the first PC consultation.EthicsInstitutional review board approval for this study was obtained and patients provided written informed consent to participate in the study. The study was performed in accordance with the Declaration of Helsinki. All patient data were handled and processed in accordance with the recommendations of Good Clinical Practice.Statistical analysisNormality of data distribution was analyzed with the Shapiro–Wilk test. The Wilcoxon signed‑rank test was used to compare ordinal data (number of drugs and tablets) before and after the intervention. In number of drugs/tablets comparisons between the subgroups of patients, the Mann–Whitney test or the Kruskal–Wallis analysis of variance with the Dunn post hoc test were performed. The Spearman rank correlation analysis was used to assess the relationship between number of errors and quantitative characteristics of patients (PPS, age, number of drugs/tablets). Number of patients with errors was compared between subgroups with the χ2 test or the Fisher exact test. Univariate logistic regression was performed to assess the relationship between errors in treatment in a given patient (dependent variable) and his/her quantitative characteristics (independent variables). Odds ratios (ORs) were reported along with 95% confidence intervals (CIs). Significance was set at P value of less than 0.05. All calculations were done with the R Project for Statistical Computing.12ResultsPatients’ primary diagnoses are presented in Table 2. Out of the 337 referred patients (323 with advanced cancer)—at the mean (SD) age of 74.2 (11.7) years—192 (57%) were admitted to the inpatient hospice, and 145 (43%), to the palliative care outpatient clinic. Death occurred in 290 of the admitted patients (86.0%). Their median length of care reached 21.5 days (interquartile range [IQR], 5.5–83.3). Three‑quarters of them had prognosis counted in weeks rather than months (GSF, stage C–D), and nearly half were bed‑bound (PPS ≤40 points; mean [SD] PPS within the group, 51.8 [22.4] points). Table 2. Diagnosis distribution of 337 admitted patientsPrimary diagnosisValueCancerTotal323 (95.8)Digestive system116 (34.4)Respiratory81 (24.0)Female reproductive system43 (12.8)Urinary tract17 (5.0)Central nervous system16 (4.7)Male reproductive system12 (3.6)Skin11 (3.3)Other27 (8.0)Nonmalignant diseases14 (4.2)Data are presented as number (percentage). The median number of drugs used at referral to PC was 7.0 (and 9.0 tablets) per day (Table 3). In the subgroup with shorter prognosis, these numbers were even higher (8.0 and 10.0, respectively). Surprisingly, only 6 patients had subcutaneous route of drug administration. Polypharmacy (≥5 medications) was found in 265 cases (78.6%) with the maximum of 22 medications (a total of 44 tablets) in 1 patient. The median number of drugs on PC appointment decreased by 1.0 (IQR, 3.0; P = 0.01). In 188 cases (55.8%) the number of drugs decreased, in 43 (12.7%), increased, and in 106 (31.5%), did not change. The median number of tablets also decreased by 2.0 (IQR, 6.0; P <0.001). In 210 of all consultations (62.3%), a reduction in the number of tablets was recommended, in 62 patients (18.4%) the proposed number of tablets increased, and in 65 (19.3%) it remained the same. Subgroup analysis revealed that bed‑bound patients (PPS ≤40 points), those referred by hospitals, admitted to the hospice, with shorter prognosis had a higher reduction of drugs and tablets at the first PC consultation. In aged patients (>75 years) more pronounced reduction of tablets was seen. Table 3. Characteristics of admitted 337 patient and the numbers of drugs/tablets receivedPatients characteristicsTotal, n (%)Drugs before, median (IQR)Drugs change, median (IQR)P valueaTablets before, median (IQR)Tablets change, median (IQR)P valueaTotal referred337 (100)7.0 (5.0)–1.0 (3.0)0.019.0 (8.0)–2.0 (6.0)<0.001Age, y≤75175 (51.9)8.0 (5.0)–1.0 (3.0)0.0110.0 (9.0)–1.0 (6.0)0.01>75162 (48.1)7.0 (5.0)–1.0 (3.0)<0.0019.0 (8.5)–2.0 (5.8)<0.001P valueb–0.010.15–0.010.01–PPS50–100181 (53.7)7.0 (5.0)–1.0 (2.0)0.079.0 (7.0)0.0 (4.0)0.060–40156 (46.3)7.0 (5.0)–2.0 (4.0)<0.00111.0 (10.3)–4.0 (6.0)<0.001P valueb–0.850.02–0.02<0.001–GSFA–B82 (24.3)6.5 (4.0)0.0 (2.0)0.098.0 (7.0)–1.0 (3.0)0.06C–D255 (75.7)8.0 (5.0)–1.0 (3.0)<0.0210.0 (9.0)–2.0 (6.0)0.01P valueb–0.010.01–0.02<0.001–Referring institutionGeneral practitioner96 (28.5)7.0 (4.3)–0.5 (3.0)0.019.0 (9.3)–1.0 (5.0)0.02Hospital147 (43.6)8.0 (4.5)–2.0 (4.0)<0.00111. 0 (10.0)–4.0 (6.0)<0.001Nonpalliative clinic96 (28.4)7.0 (6.0)0.0 (2.0)0.048.0 (6.3)0.0 (3.0)0.01P valuec–0.450.02–0.83<0.00–Admitted toHospice192 (57.0)7.0 (5.0)–2.0 (4.0)<0.00111.0 (10.0)–4.0 (6.0)<0.001Palliative clinic145 (43.0)7.0 (5.0)0.0 (2.0)0.048.0 (6.8)0.0 (3.0)0.04P valueb–0.94<0.001–0.02<0.001–Days to death1–14123 (36.5)8.0 (5.0)–2.0 (4.0)<0.00111.0 (10.0)–4.0 (6.0)<0.00115–3039 (11.6)8.0 (6.0)–1.0 (3.0)0.0311.0 (8.0)–2.0 (7.0)0.0131–9061 (18.1)7.0 (5.0)–1.0 (2.0)0.0110.0 (9.0)–1.0 (4.0)0.01>9067 (19.8)7.0 (6.0)0.0 (1.0)0.048.0 (6.0)–1.0 (3.0)0.03Discharged47 (13.9)7.0 (4.0)–1.0 (3.0)0.088.0 (6.5)0.0 (3.5)0.07P valuec–0.36<0.001–0.03<0.001–a Wilcoxon signed‑rank testb Mann–Whitney testc Kruskal–Wallis testAbbreviations: GSF, Gold Standards Framework; IQR, interquartile range; PPS, Palliative Performance Scale At least 1 instance of drug inappropriateness could be found in 238 of the patients (70%) (Table 4). The most frequent type observed was concomitant drug deficiency (the lack of medications which are usually necessary when other therapy is implemented, eg, absence of laxatives in the cases of regular administration of strong opioids), the second most numerous group comprised inadequate drug monitoring (eg, antihypertensives, steroids, diuretics, or antidiabetics). Less commonly detected were possible drug–drug interactions, duplications, or antagonisms. Table 4. Types and frequency of potential pharmacotherapy inappropriateness within the analyzed group of 337 patients referred to palliative careInappropriateness type/drugPatients, n (%)All types of potential inappropriateness238 (70.6)Unnecessary treatment in expected prognosis <3 monthsTotal142 (42.1)Proton pump inhibitors used in prevention73 (21.0)Lipid‑lowering drugs (statins)32 (9.5)Heparins in primary prevention28 (8.3)Dietary supplements (including iron for mild anemia)28 (8.3)Dexamethasone >10 d when no improvement or megestrol18 (5.3)Antibiotics for asymptomatic bacteriuria10 (3.0)Oral anticoagulants4 (1.2)Total parenteral nutrition2 (0.6)Nitrates for stable angina2 (0.6)Oral antidiabetics in type 2 diabetes to reduce mild hyperglycemia2 (0.6)Others (bisphosphonates/anticholinesterase drugs/insulin in type 2 diabetes)3 (0.9)Concomitant drug deficiencyTotal106 (31.5)No laxative when opioid administered81 (24.0)No coanalgetics in neuropathic component of pain37 (11.0)No “rescue” drug when regular opioid administered35 (10.4)No probiotic when antibiotic prescribed2 (0.6)Lack of drug monitoringTotal87 (25.8)Antihypertensives if normotensive/no control36 (10.7)Steroids without glycemia monitoring34 (10.1)Diuretics if oral fluid intake <1 l/no intake control20 (5.9)Antidiabetic without glycemia monitoring7 (2.1)Oral anticoagulant with no prothrombin time monitoring/heparins when PT >27 (2.1)Parenteral fluids if anasarca5 (1.5))Lactulose if oral fluid intake <1 l/no intake control/colic pain4 (1.2)Megestrol if diagnosed thrombosis2 (0.6)Inhaled drugs for dyspnea in uncooperative patients1 (0.3)Possible drug–drug interactions (reason for appropriateness)Total41 (12.2)Step III + step II opioids (sedation)13 (3.9)NSAIDs + corticosteroids/anticoagulants/SSRI (↑ gastrointestinal bleeding)11 (3.3)Tramadol + neuroleptic/antidepressant (↓ seizure threshold)8 (2.4)Paracetamol + antiepileptic (Stevens–Johnson syndrome/toxic epidermal necrolysis)8 (2.4)Metoclopramide + antipsychotics/SSRIs/SNRIs (extrapyramidal/serotonin syndrome)2 (0.6)Oral anticoagulant + NSAID/antiplatelet/PPI/fluconazole/metronidazole (↑ bleeding risk)2 (0.6)DuplicatesTotal16 (4.7)NSAIDs7 (2.1)Steroids3 (0.9)Neuroleptics3 (0.9)SSRIs1 (0.3)Loperamide + atropine1 (0.3)AntagonismsTotal5 (1.5)Metoclopramide + hyoscine3 (0.9)Mucolytics + hyoscine3 (0.9)Renal impairment (GFR <30 ml/min/1.72 m2)Total5 (1.5)Oral antidiabetics (excluding gliquidone)3 (0.9)Morphine/oxycodone2 (0.6)Other inappropriatenessTotal28 (8.3)Dosing errors (eg, crumbing sustained release tablets)15 (4.5)Absence of drug for severe symptom (pain/seizures/depression/delirium/thrombosis)7 (2.1)Incorrect route of administration (eg, tablets in vomiting patient)5 (1.5)Prescriptive cascade (bladder catheter for hygiene → infection → antibiotic → C. difficile)3 (0.9)No indication for specific drug (eg, H2 blocker after gastrectomy)3 (0.9)↑ increase, ↓ decreaseAbbreviations: GFR, glomelural filtration rate; NSAID, nonsteroidal anti‑inflammatory drugs; PPI, proton pump inhibitor; PT, prothrombin time; SNRI, serotonin‑norepinephrine reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor Patients who were bed‑bound (PPS ≤40 points), with the shortest life expectancy (GSF, D), who died within 2 weeks, were discharged from hospital and admitted to the hospice had more often 1 or more potentially inappropriate medication (Table 5). The sum of noticed errors correlated with patients’ lower performance status (ρ = 0.23; P <0.001), the number of taken drugs (ρ = 0.25; P <0.001) or tablets (ρ = 0.24; P <0.001). With every 1‑point decrease in PPS, the error risk increased by 2.1% (OR, 0.979; 95% CI, 0.969–0.99; P <0.001). This risk increased by 13.3% with each drug (OR, 1.133; 95% CI, 1.057–1.215; P <0.001) and by 7.4% with each tablet increase (OR, 1.079; 95% CI, 1.036–1.123; P <0.001). Table 5. Subgroup analysis of patients with drug errors (n = 337)SubgroupPatients with errorsP valueMen116 (23.5)0.55Women122 (68.9)Age, y<6027 (75.0)0.3160–75103 (74.1)>75108 (66.7)PPS50–100113 (62.4)0.0010–40125 (80.1)GSFA4 (36.6)0.001aB43 (60.6)C156 (72.2)D35 (89.7)A–B47 (57.3)0.004C–D191 (74.9)Referring institutionGeneral practitioner63 (65.6)<0.001Hospital114 (77.5)Nonpalliative clinic61 (63.5)Admitted toHospice150 (78.1)0.001Palliative clinic88 (60.7)Days to death1–760 (75.0)<0.0018–1432 (86.5)15–3030 (76.9)31–9046 (75.4)>9045 (67.2)≤30122 (78.2)<0.001>3091 (71.1)Discharged25 (47.2)–Data are presented as number (percentage). P values refer to the χ2 test.a P values refer to the Fisher exact test.Abbreviations: see Table 3 DiscussionTo the best of my knowledge, this is the first cross‑sectional study analyzing pharmacotherapy in the Polish PC population. Polypharmacy was found in more than three‑quarters of patients, which was comparable with the Portuguese population of the tertiary oncologic center consulted in PC,13 Belgian primary care patients,3 or Japanese elderly cancer patients on strong opioids, and was associated with an increased number of comorbidities.14 In Singapore, on palliative admission the mean number of medications varied between 5.6 (cancer patients) and 7.1 (in noncancer patients).15 The current study confirmed the clinical relevance of drug inappropriateness in patients admitted to PC: more than two‑thirds of patients on the first appointment had at least 1 inappropriate medication, which more frequently affected those more seriously ill (weaker and with poorer prognosis) and correlated with the number of drugs prescribed or tablets received.The most common type of error was unnecessary and, in consequence, futile treatment, taking into account the limited life expectancy and longer time lag to benefit from these drugs. Nearly half of the patients had at least 1 such medication, which is consistent with the majority of previous studies.1 The insufficient indication for prescribed drugs was also the leading inappropriateness observed in the literature, covering 23% of drugs.13 Proton pump inhibitors and lipid‑lowering drugs used in prevention were the most common examples, which might increase the risk of pneumonia, Clostridium difficile infection, or appetite loss due to the former16 or muscle pain/weakness, diabetes risk due to the later.17 The classification of many drugs as futile therapy, however, is often problematic, because disease‑specific evidence‑based guidelines for patients with advanced‑stage disease, multimorbidities, and life expectancy shorter than 1 year are lacking. In these cases, American Geriatrics Society experts advise treatment deescalation, introducing symptom management and PC.18Besides commonly observed polytherapy, the deficiency of necessary concomitant medication has currently been observed in nearly one‑third of patients. The leading example has been the absence of laxatives in spite of regular opioid administration. The majority of patients who receive opioids have not been informed of the risk of the opioid‑induced bowel disorder.19 Half of constipated patients experience moderate to severe symptoms, but only seldom (12%) are they prescribed laxatives.20 Opioids affect gut motility and secretion through multiple mechanisms, and laxatives should be prescribed unless there is a definite contraindication. PC consultants also noticed the common absence of rescue analgesics in the cases of an around‑the‑clock opioid regimen or the lack of coanalgesics in neuropathic pain (in 10.4% and 11% of patients, respectively), while these should be prescribed routinely, not only by PC specialists but also by any practitioner.21‑23Many drugs used in PC need clinical/metabolic monitoring, which has been insufficient in 25% of the current cases. This supervision refers to home blood pressure monitoring when hypertensives have been prescribed,24 as gradual dosing reduction needs to be considered even in normotensive patients with poor prognosis.6 Serum glucose monitoring is important not only when taking antidiabetics,25 but also when steroids26 or antipsychotics/antidepressants are prescribed.27 Close monitoring of hydration and fluid balance (eg, via simple body weight or diuresis) is necessary when administering diuretics,28 parenteral fluids, or osmotic laxatives.29 In the cases of obvious adverse effects of drugs, the causative drugs should be stopped (eg, megestrol when symptoms of deep vein thrombosis occur). The systematic monitoring of biochemical renal profile is also important, since renal impairment is common in PC patients.30 Estimated glomerular filtration rate reflecting the kidney function may guide drug choice and dosing.31 In the current study, 1.5% of the analyzed patients received inappropriate oral antidiabetic agents or opioids in spite of documented renal impairment.Various types of drug–drug interactions have recently been described.1 In the present study, this reason for potential inappropriateness occurred less often than other types of errors (16.6% of patients) and encompassed pharmacodynamic interactions, or the use of drug antagonists/duplicates. While interactions on the level of receptors/mediators/enzymes can cause clinically dangerous toxicities, prescribed antagonists/duplicates can additionally be described as treatment futility.Over 8% of the currently analyzed patients have shown other types of treatment malpractices, less obvious to classify, and therefore seldom published. The evident excessively high opioid dosage, the crumbing of sustained release tablets in the case of swallowing difficulties, the prescription of oral drugs to persistently vomiting patients, or ranitidine in spite of formerly performed total gastrectomy are typical examples of this subtype of malpractices. The management of drug prescriptions in patients with dysphagia was apparently suboptimal, if not iatrogenic. Within French geriatric population, 12.7% of the drug form modifications could have been harmful.32 Professionals need to reevaluate their practices to reduce this risk. Better education of patients and caregivers is urgently needed to improve treatment adherence.33Clinicians, regardless of specialty, should have rudimentary knowledge of symptom management and be skilled in the domains of utmost importance in their training. In the present study, over 2% of patients received no pharmacological symptomatic management despite the occurrence of severe symptoms (eg, pain, dyspnea, or seizures), which was particularly arresting. Although inadequate pain management can affect over 30% of cancer patients,34‑35 the complete current absence of such therapy in some persons could be daunting. In contrast, screening for opioid misuse in seriously ill outpatients could also be inadequate.36 According to what has recently been evidenced, a training in symptom management for physicians from different clinical backgrounds is likely to contribute significantly to their approach and expertise,37 so additional teaching is strongly advised. Specialist PC consultation supported by a team pharmacist can be instrumental in reducing inadequate dosage, converting one, or indicating untreated chronic moderate symptoms.38The risk of drug errors increases with the number of medications/tablets, but also when multiorgan (hepato‑renal) failure progresses or when drugs of narrow therapeutic index, which are often used in PC, are administered.39 On the first PC consultation in this study, a clinically significant reduction in the number of medications and tablets has been observed. Similar results were obtained in Portugal, where more than one‑quarter of the drugs (28.2%) was suspended (mainly due to the absence of indication for the drug) by a PC physician on the first appointment; however, no significant difference was noted between the number of drugs taken before and after this consultation.13 The curbing of the number of drugs (deprescribing) appears to be a simple method of diminishing the risk of pharmacotherapy errors. In this study, PC consultants pointed out the need for drug reductions, especially in less fit individuals with a shorter prognosis. There are various arguments for it in the elderly patients, such as the possible risk of continuing the therapy, questions about ongoing indication or benefits, prevalence of its overuse, or the availability of other treatment options—but also stopping the drug poses challenges when there is lack of evident deprescribing guidelines.40 In the majority of geriatric patients, some drugs can be limited with the consequence of survival improvement and lowering of hospital admissions.7 Similarly, in long‑term care, gradual, individualized deprescribing of some regular drugs, with active involvement of patients’ family members and a multidisciplinary team, is feasible. Most of preventive medications can be discontinued in advanced chronic obstructive lung disease, eg, 90% of the physicians would discontinue a cholesterol inhibitor when life expectancy is 3 months or less.41 The majority of people with dementia experience no withdrawal symptoms when reducing antipsychotics, which should be personalized and monitored.42 However, in the PC population in particular, this is not an effortless process, as the need of additional symptomatic pharmacotherapy usually increases as the disease proceeds. Patients with advanced cancer should be carefully followed in order to have their pharmacotherapy systematically evaluated.1 Deprescribing consists in systematically reducing or discontinuing medications with the aim to minimize polypharmacy and improve patient outcomes.4 Reducing the number of potentially inappropriate medications may result not only in a reduction of reported symptoms in the elderly but also in lowering healthcare expenditures.43 The majority of patients taking many (≥10) drugs thought they took a large number of medications (would be comfortable taking fewer of them), and they would be willing to stop at least 1 if their doctor told them they could.44 A Delphi survey among 135 palliative care clinicians in 9 countries suggested that only a few essential drugs are needed for quality care at the end of life (opioid, neuroleptic, anxiolytic, and/or antimuscarinic).45 However, a high burden of unnecessary drugs is still found on the last day of life.11 That is exactly why a management review by the primary treating clinician (eg, general practitioner when the patient stays at home) should be a substantial part of the care at the end of life. The physicians who are inexperienced in pharmacological management of terminally ill patients should turn to a palliative care specialist for consultation.46 Quellet et al47 recently proposed an iterative 3‑step approach to medication decision making in older adults that could be adapted also to the PC. It posits: a) information gathering (patients’ health priorities, disease trajectory, prognosis, and current treatment burden, b) balancing current/future possible harms with achievable benefits, and c) serial coordinated “therapeutical trials.” It is helpful to ascertain SMART (specific, measurable, actionable, realistic, and time‑limited) goals to evaluate the pharmacotherapy.48Several study limitations are to be noted. It has been a single‑institution trial reflecting palliative medicine physicians’ therapeutic judgment according to the routine clinical practice, and carried out without a formal follow‑up, hence the inability to assess the effectiveness of treatment modifications performed. Subcutaneous drugs routinely given instead of tablets within the last days of life have not been analyzed, and neither has intermittent pharmacotherapy (eg, periodical chemotherapy) been assessed.ConclusionsThe majority of patients admitted to PC are treated with multiple medications, which increases the risk of drug inappropriateness. This phenomenon affects in particular those referred by hospitals, older patients with a poor prognosis and poor condition, and those admitted to inpatient hospices. A significant drug/tablet intake reduction in these patients may be considered to diminish the risk of therapeutic inappropriateness. There is also an urgent need of therapeutic education within nonspecialist palliative care.
- Kotlińska‑Lemieszek A, Paulsen O, Kaasa S, Klepstad P. Polypharmacy in patients with advanced cancer and pain: a European cross‑sectional study of 2282 patients. J Pain Symptom Manage. 2014; 48: 1145‑1159. | Crossref
- Paque K, Elseviers M, Vander Stichele R, et al. Changes in medication use in a cohort of patients with advanced cancer: the international multicentre prospective European Palliative Care Cancer Symptom study. Palliat Med. 2018; 32: 775‑785. | Crossref
- Pype P, Mertens F, Helewaut F, et al. Potentially inappropriate medication in primary care at the end of life: a mixed‑method study. Acta Clin Belg. 2018; 73: 213‑219. | Crossref
- Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015; 175: 827‑834. | Crossref
- Lindsay J, Dooley M, Martin J, et al. The development and evaluation of an oncological palliative care deprescribing guideline: the “OncPal deprescribing guideline”. Support Care Cancer. 2015; 23: 71‑78. | Crossref
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