NEW ORLEANS – Futile and duplicate medications remain a significant burden among patients at the end of life, according to a blinded, prospective cohort study of 397 consecutive hospice patients.
At some point in their end of life care, 39% of patients received futile medications such as statins, and 19% received duplicate medications.
Patrice Wendling/IMNG Medical Media
Nehal Munshi
Reducing futile and duplicate medications provides not only a cost benefit, but also a morbidity benefit because many of these patients are frail and sometimes unable to swallow, and these medications increase pill burden and may actually exacerbate the very symptoms you’re trying to treat, Nehal Munshi said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Based on the medical literature and personal experience, the patients’ medications were independently ranked by two expert palliative care physicians and one pharmacist as appropriate, questionable, futile, duplicate, or not enough patient data to support a ranking. Consensus was achieved where there were discrepancies.
Medications in the hospice emergency kit, also known as the e-kit, were omitted from the analysis. Duplication medications were defined as two agents prescribed for the same indication when one would have sufficed.
Patients in the study were drawn from six hospice agencies in Louisiana over a 6-month period. Their median age was 80 (range 23-107), 58% were women, 72% were white, 23% black, and 0.5% Hispanic. More than one-third of patients (37.3%) died within 2 weeks of study entry.
Vitamins and minerals including calcium, iron, and fish oil supplements made up the bulk of futile medications (67%), followed by statins (21%), and other medications (12%) including allopurinol (Zyloprim and generics), Imodium, megestrol acetate (Megace), Metamucil, epoetin alfa (Epogen), alendronate sodium (Fosamax), cholestyramine (Questran), and silodosin (Rapaflo), Mr. Munshi reported.
Questionable medications were anticoagulants/antiplatelets (36%), Alzheimer’s medications (18%), electrolytes (14%), appetite stimulants (9%), and other (23%) including acetaminophen, ranitidine (Zantac), methylphenidate (Ritalin), amphetamine and dextroamphetamine (Adderall), cetirizine (Zyrtec), and Sudafed.
Prior to hospice admission, patients were on a median of 7 medications, but as many as 27 separate medications, said Mr. Munshi, a fourth-year medical student at Tulane Medical School in New Orleans. It was not possible to determine whether the average number of medications was lower for those entering hospice after being cared for by a palliative care physician.
Hospices appeared to make little headway in reducing pill burden. Only 7.3% of patients with futile medications prior to hospice admission had such medications withdrawn in hospice care.
Stripping away unnecessary medications can actually increase well being among patients entering hospice, a phenomenon known as the "hospice bounce," Dr. Louis Lux, medical director of Hospice Compassus in Austin, and director of the internal medicine clerkship at Texas A&M Health Science Center in Round Rock, both in Texas, said during a discussion of the study. He suggested that it helps patients to understand that their bodies are changing and that you’re not taking away medications, but trying to improve their quality of life.
"Sometimes it’s a choice between being able to swallow a statin or an antiemetic," he said.
At the same time, Dr. Lux cautioned that many patients are invested in their medications, and that studies have shown that abrupt cessation of statins can increase the risk of cardiovascular events in some people.
Mr. Munshi agreed that medication reduction "needs to be a team approach" including the patient, the family, community physicians, specialists, and hospice providers, but suggested that policy and practice modifications aimed at reducing futile and duplication medications, not only after the transition to hospice but potentially much earlier or prior to starting a treatment, could yield substantial benefits.
The authors reported no relevant conflicts of interest.