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Palliative and Hospice Nursing Care Guidelines 1st Edition Patricia Moyle Wright
Variation in Health Care Spending Target Decision Making Not Geography 1st Edition Committee On Geographic Variation In Health Care Spending And Promotion Of High-Value Care
Deprescribing practice in hospice medicine has expanded exponentially in recent years. This book systematically addresses the groups of extremely useful medications to manage chronic disease conditions and prevent complications. It highlights the positive intervention of reducing polypharmacy, improving a terminally ill patient’s quality of life, providing individual patient context, and helping clinicians in deprescribing. It discusses good ethics, patient wishes, side effect, protocols to discontinue no longer relevant medications, thus improving decision-making with the goal of enhancing the patient’s quality of life during the time when it is needed the most.
Key Features:
• Empowers the patient, their families, and the providers to have an open discussion about well-informed decision-making.
• Equips the hospice and palliative care clinicians to comfortably explain the rationale and the discontinuation process of nonessential medications.
• Highlights the most important facts in bullets along with a unique feature of providing ready-to-go conversational phrases.
Talking Points on Deprescribing in Hospice Care
Deepak Shrivastava
First edition published 2024 by CRC Press
2385 NW Executive Center Drive, Suite 320, Boca Raton FL 33431
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.
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ISBN: 978-1-032-49108-0 (hbk)
ISBN: 978-1-032-49105-9 (pbk)
ISBN: 978-1-003-39214-9 (ebk)
DOI: 10.1201/9781003392149
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Preface
While deprescribing appears to be one-sided process with clinical team making recommendations regarding the lack of perceived benefit in life-limiting disease and potential side effects in the face of changing physiology, such as dehydration, poor nutrition, loss of body weight, and changes in metabolism, it is important to understand that this process is likely to be more effective in achieving better quality of life for the patient and their families. Deprescribing conversation begins after establishing rapport and trust with the patient. Consideration of patient’s cultural and social beliefs and understanding how they relate to the medications help formulate strategic planning and shared decision-making. In this construct, the patient and their family are empowered to set meaningful goals and actively participate in the deprescribing process.
This handbook is a deliberate attempt based on years of hands-on experience and meeting challenges to effectively help patients participate in their own care. The content is rich in how to share information with the patient and their families explaining how their medications, which have been helping them so far, now need to be discontinued because they may potentially work against them. The handbook provides a step-by-step process of discontinuation based on
discussion of potential risks of continuing current medication, drug–drug interactions, and plain English verbiage in scripted form for simple verbal presentation to the patient and their family.
The author hopes that this volume becomes indispensable to every hospice and palliative care provider by preparing them with the next level of education.
About the Author
Deepak Shrivastava, MD, is a board-certified hospice medical director. In addition, he holds board certifications in internal medicine, sleep medicine, pulmonary and critical care medicine, and post-acute and long-term care. He is an academic and clinical faculty member at the Sleep, Critical Care and Pulmonary division at the University of California. He is an adjunct professor of pharmacy at the University of Pacific, School of Pharmacy. He is the recipient of many academic and service awards including the Medical Director of the Year award (2015). Dr. Shrivastava received his training at the State University of New York, University of California–Davis, and Stanford. He is an active researcher with a keen interest in medical education. He is directly involved in health care quality and performance improvement. In addition to his active practice of pulmonary care, critical care, and sleep medicine in an ACGME-accredited teaching program, he has been involved in the Medicare hospice benefit program since 1989. He is a member of the National Partnership for Healthcare and Hospice Innovation (NPHI). His areas of interest are clinical nursing and hospice physician education, as well as performance improvement in hospice care.
Introduction
Hospice services are patient centered and are intended to improve the quality of life during terminal illness through shared decision-making among interdisciplinary groups, along with the patient and family’s discussions. Most patients who enroll in hospice take multiple medications for their medical and mental health problems. This practice of polypharmacy increases the pill burden, possibility of drug interactions, altered drug metabolism, and side effects that ultimately lower the patient’s quality of life.
Polypharmacy is considered the new epidemic, and many patients take three to five or more medications per day with multiple dosing schedules. The number of medications and prescribers directly correlates with increased risk of errors in taking the pills. Many times, a complete list of all medications that a patient is taking is not available.
In addition, patients self-select over-the-counter medications, herbal products, and nutritional supplements, further
adding to the complexity. There are many drug–drug interactions, side effects of certain medications, and the possibility of making errors in medication intake.
The life expectancy of the hospice patient is short compared to the general population. The life-prolonging and illness-preventing medications and interventions are no longer relevant to the hospice population.
Pills come in different sizes and shapes, and many medication names sound and are spelled alike. The formulations are available in the form of injections (e.g., insulin), tablets and capsules, skin patches, and inhalers. Any level of cognitive impairment or distraction on part of the patient, caregiver, or provider can potentially lead to administration of wrong medication, wrong dosage, and/or wrong timing, with increased potential for undesired complications.
Medication side effects are often so troublesome to the patient that they stop taking that particular medication altogether, with the resultant worsening of their health problem. Unfortunately, many of the side effects are managed by adding another medication. For example, it is a requirement to use laxatives to avoid constipation brought on by opiatebased medications. This often leads to a prescription cascade.
With the progression of disease, as the patient becomes frail and more dependent on caregivers for support, the increased pill burden further complicates the situation for caregivers.
Many medications are not covered by the hospice formulary, and copay and self-pay costs can be significant. While deprescribing medication unrelated to the terminal diagnosis, as well as potentially harmful medications, one must consider the patient’s goal of care, their values and preferences,
as well as life expectancy. Each drug should be evaluated independently, and recommendations should be made on a case-by-case basis.
This handbook is designed to empower the patient, their families, and care providers to make informed decisions regarding discontinuing medications that no longer are meaningful to continue as the patient is going through terminal illness. This also serves to provide communication tools and understanding of nuances of discontinuing medications in a broad sense so that benefit to the patient can be demonstrated with an unbiased educational approach.
KEY POINTS
• Polypharmacy is common.
• Typical hospice patient takes approximately 10–15 medications.
• Many medications are no longer required for prophylactic purposes.
• Patient may not have the ability to use certain medications like inhalers.
• It is important to discuss patient life expectancy, their goals of care, and preferences.
• A shared decision-making process is recommended to discontinue medications.
Physiologic Changes of Terminal Illness
With advancing age, the pharmacokinetics of drug absorption, metabolic, and drug elimination changes, with the resultant need for reduced dosage to prevent side effects and maintain therapeutic efficacy. Nearly all terminally ill patients in hospice care progressively become malnourished and dehydrated. This leads to inadequate protein, fat, and water concentration in the body and increases the drug’s volume of distribution. Many drugs therefore can cause side effects and potential toxicity. In addition, most drugs are metabolized through the liver using the cytochrome P system. The efficiency of this system is also impaired in terminal illness.
As negative physiologic changes occur in the body with the progression of the terminal illness, the nutritional status declines and a catabolic state begins to set in. There is loss of
protein, muscle mass, body fat, and hydration. Water is essential for the normal functioning of the human body, tissue and joint lubrication, and maintenance of body temperature.
Medications themselves induce dehydration by decreasing thirst sensation; increased liquid elimination via urine, feces, or sweat; and altered temperature regulation. Other drugs cause confusion, increase in body temperature, and hypersensitivity reactions. Diarrhea is a common druginduced mechanism that increases water elimination.
Normally, renal function declines as a function of age by approximately 20% between the ages of 40 and 65 and 25–45% between the ages of 40 and 80. This decline can increase unpredictably in a terminally ill person. A good clinical example in the context of the hospice is the use of the glipizide group of medications, specifically metformin. In this setting reduced renal function can cause slow drug clearance and episodes of hypoglycemia.
Similarly, liver function declines approximately 10% per year in the general population and again declines more during terminal illness. This can directly affect and decrease the rate of drug metabolism as well as excretion of the drug and its metabolites. Coexisting conditions like congestive heart failure further confound the problem. There are vasodilatory and impaired anticholinergic systems that affect sweat production and body temperature changes.
Medications like metformin, despite their excellent safety profile, affect the digestive system, and their metabolism may cause gastrointestinal disturbances including diarrhea, nausea, and dyspepsia in many patients. There are structural similarities between metformin and the selective serotonin receptor inhibitors (SSRI) group of antidepressant medications. Metformin
also decreases appetite. In declining renal function metformin can cause lactic acidosis, a condition that can be made worse by the concomitant use of antihypertensives like angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers (ARBS).
Antacids and laxatives may induce dehydration. Proton pump inhibitors (PPI) develop microscopic colitis and can cause persistent watery non-bloody diarrhea, worsening dehydration. Diuretics are used for the management of several conditions. They can cause dehydration and other electrolyte disorders. Beta-blockers have their effect on thermoregulation. Beta-blockers also reduce mean arterial blood pressure. Other commonly used cardiac medications like digoxin can cause weakness, lethargy, loss of appetite, nausea and vomiting, as well as cardiac arrhythmias.
Furthermore, cholesterol-lowering agents commonly known as statins can cause diarrhea and in a small percentage of patients can cause dehydration. Musculoskeletal system drugs, genitourinary system drugs, common hormonal medications, anticancer and immunomodulating drugs, as well as antimicrobials all affect the state of hydration. Many respiratory system drugs have anticholinergic properties that can alter thermoregulation.
Nervous system drugs used for Parkinson’s disease and other progressive neurodegenerative diseases can cause significant side effects and contribute to dehydration. Commonly used musculoskeletal system drugs such as over-the-counter and prescription nonsteroidal antiinflammatory drugs (NSAIDs) and aspirin preparations can lead to significant changes in water balance and participate in dehydration.
KEY POINTS
• Significant physiologic changes take place during terminal illness.
• The metabolism of most medications is significantly altered due to physiologic changes.
• Changes in the functioning of liver and kidney significantly alter processing and elimination of the drug from the body.
• This can result in accumulation of the drug in the body and cause unpredictable side effects.
• Dehydration is a common process that underlies terminal illness.
Fundamentals of Deprescribing
Reviewing multiple medications in general is a complex and time-consuming exercise. Besides the relatedness of the medications to a patient’s terminal diagnosis and secondary diagnosis, there are other factors that must be considered in the decision-making before medications can be discontinued.
A broader view includes medications that improve a patient’s day-to-day quality of life and others that prevent future illness caused by chronic disease processes. The importance is to minimize the variance between the provider recommendations and patient’s acceptance. Some of the important factors include patient preferences, clinical indication and benefit to the patient, appropriateness of the medication use, duration the patient has been using that medication, patient adherence to the treatment recommendation, and the prescribing cascade.
The identification of anticipated disease trajectory should be balanced with the choice of drugs to be discontinued and their impact on the patient’s psychological profile. Deprescribing is a continuous process with ongoing monitoring and meticulous decision-making. Medications that are not in alignment with the patient’s goal of care and life expectancy should be considered for discontinuation. Nearly all drugs have side effects that can potentiate with metabolic changes as the body declines. High risk of unwanted side effects is generally associated with polypharmacy, defined as use of five or more drugs on a routine basis. Most preventative medications provide protection against the disease after many years of use. Few examples include antihypertensive, statins, and bisphosphonates-like medications. In the face of limited prognosis, such protection may not be realized.
An immediate goal of hospice care is palliation of the current symptoms and management of disease-related complications. Medications should be chosen based on the efficacy and safety profile. Consideration of the patient’s preference and goals of care regarding the use of medications is of primary importance. It provides psychological support to the patient. It can be counterbalanced with continued education.
During deprescribing discussion several criteria should be considered, including patient life expectancy, symptom burden, comorbid conditions, functional status, and the pill burden. Such analysis helps the provider identify medications that are causing more harm than benefit. In this context patients can be reassured that discontinuing medication can always be resumed if clinical needs arise. It is equally important to approach deprescribing discussion with compassion and sensitivity, providing a plain explanation in the patient’s
preferred language. The rationale for discontinuation with explicit review of risks and benefits of each medication over multiple sessions provides a good foundation for shared decision-making.
Prioritizing and discontinuing medications, in addition to being cost effective, is a good way to simplify prescription schedule, decrease pill burden and chances of side effects, and increase therapy effectiveness. Deprescribing decisions should be patient centered and made in conjunction with patients and their family and caregivers.
KEY POINTS
• Deprescribing consideration is a complex process.
• Comprehensive assessment of indications for medication use and current setting is important.
• Risk-versus-benefit analysis should be carefully completed.
• A proactive plan to monitor the patient must be in place before discontinuing the medication.
• Discontinuation of the medication should be aligned with the patient’s goal of care and preferences.
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Here are eighteenscore changes wanting one, which one if it were made double as the former, would bring the bells round, therefore an extream must be made as in this change 123465, the two hind bells making the extream, and the bells in the 3d and 4th places making the single. Now in regard that this extream is made the second time the whole-hunt leads after a double bob, therefore the second extream must be made the second time the whole-hunt leads after the third double bob following.
This peal may be rung with any hunts, and to begin the changes triple and double as in this here prickt.
Fifty three L -Peals upon Five, Six, Seven, and Eight Bells, composed by F.S.
Crambo.
The changes are all single; it hath a perfect course, and may be prickt many ways.
The treble hath a perfect course as in plain changes. And when it hunts up out of the 2d place it makes two singles together, and the like when it hunteth down. When it leads, the single is in the 3d and 4th places, except when 2 lies next it, and then an extream behind. Every bell (except the treble) leads four times, and lies still behind untill the treble displaceth it, except at the extream.
One change is double, the next single, and so by turns.
New Doubles and Singles. 1 and 2.
One change is double, the next single, and so by turns. The treble hath a direct hunting course up and down as in plain changes, and every time it goeth to lead and leaves leading, the change is double on the two first and two last bells, the rest of the double changes are on the four first. The treble is one of the two bells that makes every single change except when it leads, and then the single is made in the 3d and 4th places; but when the 2 lies next the 1, then an extream is made behind. When the treble leaves the two first bells, they continue slow dogding until treble comes down and displaceth them. Every bell (except the treble) lieth twice in the 3d place.
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The Morning Star. 1 and 2.
The treble hath a direct hunting course as in plain changes; and every time it hunts up, it makes two singles together, and the like when it hunts down: when it leads the single is behind, but when 2 lies next it an extream is made in the 3d and 4th places. Every time the treble goeth to lead and leaves leading, the double is on the two first and two last bells, and every bell except the treble leads four times together.
This peal consists most of double changes; the treble hath a direct hunting course as in plain changes, and every time it hunts up and down it makes a single in the 3d and 4th places; and when it leads, the single is behind, but when 2 lies next it an extream is made in the 3d and 4th places.
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When the treble leaves the two hind bells, they continue dodging untill it comes up again and displaceth them, and then they hunt directly down; the first to lead, and the other into the 2d place: that which moves to lead, having lead four times, gives place to the treble; but when the Treble hath done leading it takes the treble’s place
again, and leads four times more and then hunts directly up; the other bell which moved down into the 2d place lies there twice, and then the Treble in hunting down moves it into the 3d place where it lies still, untill the Treble in hunting up moves it back into the 2d place, where having lain twice it hunteth up. This Peal is as musical, easie, and practical as any of this kind that ever was prickt.
The Faulcon. 1 and 2.
This Peal consists most of double changes. The treble hath a direct hunting course as in plain changes, and every time it hunts up and down it makes a single in the 3d and 4th places, and when it leads a single is also made there, but when 2 lies next it the extream is made behind. When the treble leaves the two first bells they continue there until it comes down again and displaceth them, but observe, when the treble moves into the 5th place, and again from thence, the double is on the two first and two last bells, by means of which the two first bells then dodg, but before and after they lie still. Every bell lies twice in the 3d place and then hunts up, except that which lies there when the treble leaves leading.
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Merry Andrew. 1 and 2.
One change is double, the next single, and so by turns. The treble leads four times, lies behind four times, and twice in every other place. Every other bell leads four times. When the treble leaves the two hind-bells, they continue dodging untill it comes up again and displaceth them. Every single is made behind until the treble hinders, and then in the 2d and 3d places. When the treble leads and the 2d lies next it, then an extream is made in the 3d and 4th places.
When the treble goes to lead and leaves leading, the double is on the two first and two last bells, and when every other bell goes to lead and leaves leading, the double in on the four first.
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May-day. 1 and 5.
One change is double, the next single, and so by turns. When the treble goes to lead and leaves leading, the double is on the two first and two last bells; and when every other bell goes to lead and leaves leading, the double is on the four first.
The treble hath a constant dodging course, for in its hunting up it first makes a dodg in the second and third places, and then another behind, and then it lies still one change in the 5th place; then in its hunting down it makes another dodg behind, and also another in the 2d and 3d places, and then leads four times. So that the treble in one of the two bells that makes every single until it leads, and then ’tis made in the 2d and 3d places, except when the 5th lies behind, and then an extream is made in the 3d and 4th places. When the treble leaves the two hind-bells they continue slow dodging, until it comes up again and displaceth them. Every bell leads four times.
The changes are all double except one single every 2d time the treble leads, there being six in the peal. The treble is a perfect hunt; and every time it goeth to lead and leaves leading, the double is made on the two first and two last bells, at which changes the bells in the 3d place lie still and then move down, and the two hind-bells at the same time dodg: but at other times all the bells have a direct hunting course. When the treble leads, and the 2d lieth either in the 2d or 3d places, then a single must always be made betwixt the two next extream bells to the 2d.
The changes are all double except six singles as the former. The treble is a perfect hunt; and every time it moves up into the 5th place, and also out of it, the double is then made on the two first and two last bells, at which time the bells in the 3d place do lie still and then move up; and the two first bells at the same time dodg. When the treble leads, and the 2d lieth either in the 2d or 3d places, then a single must always be made betwixt the two next extream bells to the 2d.
In this and the former peal the singles may be made in another manner, viz. when the whole-hunt leads, and the half-hunt lieth either in the 4th or 5th places, a single must then be made betwixt
the two next bells to the half-hunt; but at other times a double change to be made when the whole-hunt leads, as in the former way.
Stedman’s Principle.
The changes are all double, two singles excepted. One double is made on the two first and two last bells, the next on the four last, and so by turns successively; excepting every sixth change, which is double on the four first bells, and for distinction is called a Parting change. All the bells have a like course. The general method is this; the three first bells go the six changes, and the two hind-bells in the mean time dodg; then a Parting change is made which parts the two hind-bells, moving that in the fourth place down into the 3d, and that in the 3d place up into the 4th, and then the three first bells go the six again, the two hind-bells in in the mean time dodging as before; and then another Parting change is made, and so successively on. Every bell that comes behind continues there dodging six changes with one bell and six with another, and then in course the Parting change brings it down. One six cuts compass, the next doth not, and so by turns successively. In the six which cut compass the two first bells of the three makes the first change of it, but in the other the two last of the three. By this method the peal will go sixty changes, and to carry it on farther extreams must be made. An extream is made by the lying still of two bells when in course they should make a change, as before I have shewed more fully in the Introduction, page 90. but withall observing, that whereas in this peal the bells have all a like course, therefore they may all be termed extream bells, and consequently the extreams to be made according to this general rule, viz. the first extream may be made by any two bells that are in course to make a change within the compass of the first sixty changes of the peal; and the second extream must be made according to this rule. Whatsoever two bells are dodging behind at the first extream, when the same two bells come to dodg there again, is a certain warning for the second extream to be then made. And observe, how many changes the first extream is made from a parting change; so many likewise must the last extream be made after a Parting change also. And the single and extream comes in course each of them to be made in the same place and by the same bells at the last extream, as they were at the first. Here the singles are made
behind, and the extreams in the 2d and 3d places; and as the 4th and 5th bells do dodg behind at the first extream, so likewise when they come to dodg there again, the second extream is then made, the treble leading at both of them, as appeareth in the peal here prickt.
The first Parting change is here made the third change at the beginning, and that six cuts compass.
In all the several ways of ringing this peal, if the Parting changes are made at the fore-stroke, as in course they are in this here prickt, then cutting compass is always on the same sixes, as in this peal: but when the Parting changes are made at back-stroke, then the contrary six always cuts compass to what doth here.
Peals upon Six Bells.
The single Method.
The changes are all single, and treble is the hunt. When the treble moves up out of the 2d place, the two first bells continue slow dodging untill the treble comes there again. And when the treble moves down out of the fourth place, the two hind-bells likewise continue slow dodging until the treble comes there again. When the treble leads, (if ’tis rung at half-pulls) the fore-stroke change (that is, at the third stroke of the treble’s leading) is made in the 3d and 4th places, the rest of the changes there are made behind. By this method it will go sixscore changes.
To ring 240. When the whole-hunt leads, and the half-hunt dodgeth behind; the fore-stroke change must then be made in the 2d and 3d places, as in this here prickt, where the 2d is the half-hunt and there are little marks set at the fore-stroke changes.
To ring 360. When the whole-hunt leads, and the half and quarter-hunts dodg behind, the fore-stroke change must then be made in the 2d and 3d places as before.
To ring 720. When the whole-hunt leads, and the half-hunt dodgeth behind, the fore-stroke change must then be made in the 2d
