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Discontinuing Medications:Dialogues for Nurses, Physicians,
Patients & FamiliesAllison M. Webb, RPh, PharmD, CGP
Clinical PharmacistHospiScript, a Catamaran Company
T&NMHO Annual Conference April 26, 2014
Objectives
• Identify principles of decision making about drug treatment in end of life care
• Describe strategies for communicating discontinuation of medications with patients/caregivers
• Describe communication strategies when addressing changes or discontinuing medications with healthcare providers
Why Is This Important? • Medication risk outweighs benefit• Lack of evidence to support continuation of
therapy• Does not meet patient plan of care• Therapeutic benefit is diminished• Polypharmacy• Meeting Conditions of Participation (CoP)
requirements for Medicare
Why Is This Important?Cost of therapy
• For patients & families• For hospice• Hospice medication coverage and hospice
payment structures
Discontinuing Medication Late in Life
Prioritize based on the following information:• Remaining life expectancy • Time until benefit • Goals of care • Treatment targets
A Model for Appropriate Prescribing
Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9.
Medication Evaluation
The Medication Appropriateness Index:• Indication?• Effective?• Correct dose and directions?• Practical directions?• Interactions? (with drugs or disease states)• Duplications?• Duration acceptable?• Less expensive alternative available?
Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9
Medications: When to Stop?
Medications that either:• Have limited evidence to be continued at end of
lifeoVitaminsoStatins
• Lose efficacy as the disease trajectory changesoAcetylcholinesterase inhibitorsoPulmonary medications oAnticoagulantsoAntidiabetic medications
What Medications Could be Considered for Discontinuation?
Antihyperlipidemic Medications• Statins could reduce risk for vascular events after
about 2 years of treatment and significantly reduce cardiovascular events at 5 years of therapy
• No additional palliative benefit • Limited prevention of atherosclerotic heart disease
with short prognoses• Increased pill burden: patients with difficulty
swallowing• May require liver function testing • Potential side effects: myopathy/rhabdomyolysis
Anticoagulants
Evaluate:• Indication• Prognosis• Route of administration• Bleeding risk• Nutritional status• Appropriate monitoring• Medication adherence• Medication changes• Patient/family preferences
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Will a new clot impair patient’s function or quality of life?
AnticoagulantsPrepare the patient and family
• Discuss “early”• Provide options for potential changes in therapy• Educate on patient decline (to help patient and
family make their decision)o Decreased renal functiono Decreased nutritional intakeo Swallowing statuso Increased bleeding risk
Dementia Medications
Typically, dementia has progressed beyond the point of benefit with these agents when:
• Patient has declined rapidly despite therapy• Patient is no longer able to regularly make their
needs known and/or ambulate by themselves• Patient can no longer complete activities of daily
living (ADLs) without assistance• Functional Assessment Staging (FAST) score has
progressed to a 7b or greater
Dementia Medications
• Appropriateness of these medications should be evaluated routinely
• Discussions should include:oGoals of careo Perceived benefit of treatmento Patient prognosiso FAST scoreo Eventual discontinuation when no longer
beneficial
Dementia Medications
• What if there is resistance from family members?o Try a trial of a decreased dose and monitor for
changes in the patient’s status or symptomso If no change or improvement witnessed with
decreased dose, the medication is no longer providing benefit and could be discontinued
• Should you titrate doses when discontinuing?o May consider titration, if possibleo If patient is not swallowing, it may be appropriate to
stop abruptly
Anti-Diabetic Medications• The American Diabetes Association and the American
Geriatric Society have stated that blood sugars need not be held to less than 180-200mg/dL for patients near the end of life. Many clinicians set the threshold at 250mg/dL.
• Tight glycemic control (fasting glucose <= 110mg/dL) near end-of-life carries the risk of hypoglycemic episodes
• Managing blood sugar to 180-250mg/dL allows for lower doses or elimination of anti-diabetic medication and reduces risk of hypoglycemia
Bisphosphonates• It is not necessary to treat osteoporosis in hospice
patients • Esophageal erosions can occur if not taken with a
full glass of water with patient remaining straight up for 30-60 minutes after administration
• Potential residual therapeutic effect after discontinuation appears to be sustained 2-5 years
• Patients should take calcium and vitamin D supplementation during therapy
Pulmonary Medications
Major concerns:• Inability to properly use inhalers
oInhaler techniqueoCognition
• Over utilization of beta-agonists and anticholinergicsoDuplications of therapyoIncreased risk of adverse effects
Pulmonary Medications
Signs and symptoms that a patient may have poor inhaler technique:
• Thrush• Pneumonia• Exacerbation• Increased utilization• Bed bound• Agitation or delirium
Pulmonary MedicationsEnd stage respiratory cycle• Over use of beta-agonists and
anticholinergics leads to increased systemic absorption and CNS stimulation
• Increases in release of catecholamines leads to increases in HR, decrease in oxygen exchange, and anxiety
= Shortness of Breath
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Vitamins and Supplements • Limited evidence to be continued at end of life• Offer little or no additional palliative benefit• Increased pill burden
o Troublesome for patients with difficulty swallowing
• Increased potential for drug-drug interactionso Calcium and iron can decrease absorption of other medicationso Many herbal supplements increase bleeding risk with concomitant
anticoagulants/anti-platelet medications
• Increased potential for side effectso Iron supplements can worsen constipation and nausea
Vitamins and Supplements
When might it be appropriate to continue vitamins and supplements?
• Folic acid during methotrexate therapy• Thiamine and folic acid during acute alcohol
withdrawal syndrome• Iron supplementation during erythropoietin-
stimulating agent therapy
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Medications That May Need Tapering
• Anti-depressantso Paroxetine (Paxil®) and venlafaxine (Effexor®) are most
difficult to discontinueo Fluoxetine (Prozac®) may not require taper because of
long half-life• Anti-psychotics
o May need to taper one while titrating up anothero Gradual dose reductions
• Anti-epilepticso Taper after new agent is at effective doseo Regardless of use for seizures, neuropathy, or behaviors
Medications That May Need Tapering
• Beta-blockerso Taper over 1-2 weeks
• Clonidine (Catapres®)o Taper over 1 weeko If also taking beta-blocker, taper beta-blocker first
• Tizanidine (Zanaflex®)o Taper over 1-2 weeks if on longer term, higher doses
• Baclofen o Taper over 1-2 weeks
Medications That May Need Tapering
Corticosteroids, benzodiazepines, opioids• All three classes should be tapered• Unusual to discontinue in hospice• Equivalent dosing strategies allow for
rotation to alternative agents• Ask for assistance from your medical
director and/or pharmacist
What If There’s No Time to Taper?
• Be alert to side effects of abrupt withdrawal:o Rebound hypertension, tachycardiao Agitationo Seizureso Paino Nauseao Sweating
• Rely on supportive care and comfort meds • Contact medical director or pharmacist if concerned
How Do You Have These Conversations?
Communicating with patients, families, and other practitioners about letting go
of medications
Communication Barriers
• Patient sense of abandonment• Fear of losing control• Fear of losing hope• Importance of maintaining attending physician
relationship• Cultural concerns
– Who is decision-maker?– Herbal supplements, home remedies?
How Do These Discussions Occur?
PatientCentered
Care
Building
Understanding
InformingListening
Developing
The BUILD ModelB: Build a foundation of trust and respect.U: Understand what the patient and caregiver know
about the medication and disease progression.I: Inform the patient and caregiver of evidence-based
information.L: Listen to the patient’s and caregiver’s goals and
expectations.D: Develop a plan of care (POC) in collaboration with
the patient and caregiver.
B-BUILD A foundation of trust and respect with the patient and caregiver
Goal: affirm the patient and caregiver; listen more than you talk.
B-BUILD A foundation of trust and respect with the patient and caregiver
Key phrases:• “Thank you for taking the time to talk with me.”
• “You do a great job advocating for your mother.”
• “As you know, cancer doesn’t just happen to the patient; it impacts the entire family. This must be very difficult for you.”
U – UnderstandWhat the patient and caregiver know about the medication, disease
Goal: learn the patient’s and caregivers’ understanding and expectations of the medications.
• Ask open-ended questions• Facilitate the patient/family drawing their own
conclusion that the medicine may no longer be effective
U – UnderstandWhat the patient and caregiver know about the medication, disease
Key phrases:• “What has your doctor told you about how this
medicine works?
• “What do you think your mother will look like when the medicine is no longer effective?
• “How will you know it’s time to stop or change the medicine?”
I – InformThe patient and caregiver about appropriateness of medications
Goal: provide evidence-based information in a non-threatening, non-coercive way.
I – InformThe patient and caregiver about appropriateness of medications
Key phrases:• “Here’s what we know about this medicine.”
• “As your disease progresses we will probably need to make some changes in your medications. What worked before may not work now.”
• “There are other medications that may be more helpful for you at this time.”
L – ListenTo the patient and caregiver as they share goals and
expectations
Goal: learn what is important to the patient and family.
L – ListenTo the patient and caregiver as they share goals and
expectationsKey phrases:
• “How can I be of help to you at this time?”
• “We can’t reverse or cure your disease, but there are many things we can do to provide comfort and quality-of-life. What does quality of life look like to you?”
• “Did your mother ever share her thoughts about what she would want if she had dementia?”
D – DevelopA POC in collaboration with the patient and caregiver
Goal: empower the patient/caregiver to direct their care
• Increases compliance with the POC• Offers choices for the patient and caregiver
D – DevelopA POC in collaboration with the patient and caregiver
Key phrases:• “Here are some choices: we can continue with the current
regimen and not make any changes. Or, we can decrease the Aricept and re-evaluate your mother’s condition in one week.”
• “My job is not to make decisions for you, but to provide you with information so that you can make informed decisions. What questions do you have about what we’ve talked about?”
• “We will work in collaboration with you and your doctor. S/he still guides your care."
Planned Discussions• At time of admission• Prior to recertification• During a family or facility care conference• When it’s time to re-order a medication that is
regarded as delaying disease progression or no longer effective, i.e. riluzole, donepezil
• When filling the patient’s pillbox or ordering refills
Planned Discussions• Change in location or level of care due to a change in
patient condition:o Transfer to inpatient unit (IPU)o Transfer to an extended-care facility (ECF)o Continuous care initiated
• Whenever there is a need to change medications due to patient condition:o Patient having difficulty swallowingo Patient less responsive
Windows of OpportunitySeizing the moment:
• “He takes pills all day long. No wonder he doesn’t have an appetite.”
• “It takes 20 minutes to get his pills in him.”• “I’m having to use my inhaler more often, sometimes
every 2 hours.”• “I can’t even walk to the door anymore because I’m
so short of breath.”• “Mom doesn’t even say my name anymore.”
Windows of OpportunityCreating the moment:
• “You take a lot of medications, I’m wondering if some may be causing side effects?”
• “With so many medications, I’m wondering if you ever prioritize the ones that are most important and skip others.”
• “I’m wondering if it’s difficult for you to think about discontinuing medications that your mother has taken for a long time.”
BUILD: Clinician Communication
PatientCentered
Care
Building
Understanding
InformingListening
Developing
BUILD: Clinician Communication• Collaboration with clinician• Trust as a skilled practitioner
o Both of you are doing the best for the patient
• Respect for the patient/prescriber relationshipo Affirm the prescriber’s efforts, knowledge and
commitment to the patient
• Evidence-based practiceso Ask questions in IDT
• Information on patient conditiono Paint a clear, succinct picture
Mrs. Shirley• 80 y/o with lymphoma, anemia• Primary caregiver for husband with dementia• Recently stopped chemotherapy and considering
hospice admission for extra help at home• Weak, tired, short of breath• Hgb not improving despite use of erythropoesis
stimulating agent, Procrit®
How can you use the BUILD model to start a conversation about discontinuing Procrit®?
Mrs. Shirley
Your discussion with Mrs. Shirley was effective, and she has agreed to stop Procrit®
How can you use components of the BUILD model to effectively communicate with the
prescriber?
Summary
• Evaluate every medication for appropriateness
• Use resources to practice evidence-based medicine
• Practice effective communication• Use the BUILD Model as a tool
o Build, Understand, Inform, Listen, Develop!
References & Further Readings
• Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9.• Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope.
New York: Cambridge University Press; 2009.• Lautrette A, Darmon M, Megarbane B, et al. Communication strategy and brochure for relatives of dying patients in the ICU.
N Engl J Med 2007;356:469-78.• Jackson VA, Back AL. Teaching communication skills using role-play: an experience-based guide for educators. J Palliat Med
2011;14(6):775-80.• US Admin on Aging. The art of active listening. Aging I&R/A Tips. Tip Sheet 1. National Aging Information & Referral Support
Center. 2005. Available from: http://www.mitoaction.org/pdf/tipActiveListening.pdf• Buckman R. Practical plans for difficult conversations in medicine: strategies that work best in breaking bad news.
Baltimore, MD: Johns Hopkins Press; 2010.• National Health System (NHS) Trust. Difficult conversations: guidelines for staff. King’s Health Partners; 2011. Available
from: http://www.gsttcharity.org.uk/media/4294/difficult_conversations_booklet_final.pdf• Cramer C. How to have difficult conversations with patients, families. Oncology Nursing Society, 37 th Annual Congress. • Silveria 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.• American College of Chest Physicians Evidence Based Clinical Practice Guidelines: Antithrombic therapy and prevention of ‐
thrombosis, 9th ed. Chest. 2012; 141(2_suppl), p7s 690s. Available from: http://journal.publications.chestnet.org/‐
References & Further Readings
• Noble SIR, Nelson A, Finlay IG. Factors influencing hospice thromboprophylaxis policy: a qualitative study. Palliative medicine. 2008;22:808-813.
• Hill RR, Martinez KD, Delate T, et al. A descriptive evaluation of warfarin use in patients receiving hospice or palliative care services. J Thromb Thrombolysis. 2009;27:334-339.
• Winblad B, et al. Donepezil in patients with severe Alzheimer’s disease: double-blind, parallel-group, placebo-controlled study. Lancet 2006;367:1057–65.
• Qaseem A, Snow V, Cross Jr. JT, et al. Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2008;148:370 378.‐
• Weschules DJ, Maxwell TL, Shega JW. Acetylcholinesterase Inhibitor and N Methyl D Aspartic Acid Receptor Antagonist Use ‐ ‐ ‐among Hospice Enrollees with a Primary Diagnosis of Dementia. J Palliat Med. 2008;11(5):738 745.‐
• AACE Diabetes Care Plan Guidelines, Endocr Pract, 2011;17(Suppl 2).• American Diabetes Association (2010). Position Statement: Diagnosis and Classification of Diabetes Mellitus. Diabetes Care,
33,Suppl 1, S5-S10. DOI: 10.2337/diacare.27.2007.S5.• Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in elderly patient with chronic obstructive
pulmonary disease. Am J Health Syst Pharm. 2011;68:1221-1232.• End Stage COPD Guidance Document. HospiScript Servies, LLC. 2013.• Common oral medications that may need tapering. Pharmacists Letter 2008;24:241208• Collier KS, Kimbrel JM, Protus BM. Medication appropriateness at end of life: a new tool for balancing medicine and
communication for optimal outcomes-the BUILD Model. Home Healthc Nurse 2013;31(9):518-24.
