Deprescribing of medications at the end of life

Date: 
03-04-2019

Author: Kristel Paque, Promotors: Prof. dr. Thierry Christiaens (Ghent University), Prof. dr. Luc Deliens (Vrije Universiteit Brussel), Prof. dr. Koen Pardon (Vrije Universiteit Brussel)

Data of older adults living at home or in a nursing home, and patients with advanced cancer receiving palliative care

Background
Older adults and people with advanced disease, such as patients with cancer, use many medications, but not all of these medications are appropriate in the
last year of life. Of course, medications are needed to treat symptoms such as pain, but some medications might cause additional harm due to side-effects. When death approaches, people really
do not need this additional harm.

Aims & methods
In this study, we investigated by means of assessing information limited to drug lists with minimal additional clinical data, how many medications and potentially inappropriate or unnecessary medications were used at the end of life, and which medications were involved. Moreover, we examined if, and to what extent, medications considered suitable for deprescribing were actually deprescribed in the last year of life. Deprescribing means judicious tapering or stopping potentially inappropriate medications. We examined these aspects in nursing home residents, as well as in all people aged 75 years and older who died in Belgium in 2012, and in people with advanced cancer receiving palliative care in Belgium and 12 other countries in Europe. Furthermore, we summarized the existing literature on factors that hinder and/or facilitate deprescribing of medications in people with life-limiting diseases.

Results
Our most important findings are that, in all groups studied, the use of medications and potentially inappropriate or unnecessary medications was high and increased in the last year of life. This finding was applicable to the number of medications as well as the prevalence of most medication groups. The number of people for whom – potentially inappropriate or unnecessary – medications considered suitable for deprescribing were actually deprescribed, was limited to one out of five in the Belgian population aged 75 and older who died in 2012, and to one out of three in nursing home residents.
We distinguished three types of factors that can hinder and/or facilitate judicious deprescribing of medications: factors related to (1) the organization, (2) the healthcare professionals (physicians,
pharmacists, nurses, …), and (3) the patient and his family. The most important factors that can facilitate judicious deprescribing were (1) organizational support for standardized meetings to evaluate and review the patient’s medication chart, (2) a positive collaboration between different healthcare professionals, and (3) explaining clearly the pros and cons of medications to the patient and his family.
The most important factors that can hinder judicious deprescribing were: (1) shortages in staff, (2) communication and collaboration between healthcare professionals that was hindered by
hierarchical and traditional norms, and (3) the patient and his family’s misconception about the indicated duration of pharmacotherapy.
Generally, in Belgium similar to other countries in Europe, medications are seldom reconsidered in the last year of life. Judicious deprescribing of medications is very limited in this situation. Apparently, many factors that hinder judicious deprescribing at the end of life exist. It is crucial to explore these factors more in detail before we start thinking about how to tackle this problem in daily practice. 

 
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