Terminally ill cancer patients with limited life expectancies (LLEs) are often prescribed multiple medications to control acute symptoms associated with cancer such as dyspnoea, pain, nausea and vomiting, and anxiety. Medications are also commonly prescribed to prevent or treat other common, long-term comorbid conditions such as hypertension, diabetes mellitus and hyperlipidaemia. Early identification of unnecessary preventive medications at the end of life can improve quality of life. Limited research has investigated whether preventive medications are withdrawn in patients with terminal cancer. The aim of this project was to evaluate the prevalence of preventive medication use in terminally ill cancer patients with LLE of 6 months or less.
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Background: Multimorbidity and pain are both common among older adults, yet pain treatment strategies for older patients with multimorbidity have not been well characterized.
Objectives: To assess the prevalence and relationship between multimorbidity and opioid prescribing in hospitalized older medical patients with pain.
Methods: We collected demographic, morbidity, pain, and analgesic treatment data through structured review of the electronic medical records of a consecutive sample of 238 medical patients, aged =65 years admitted between November 2014 and May 2015 with moderate-to-severe pain by numerical pain rating scale (range 4–10). We used the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) to assess multimorbidity and cumulative illness burden. We examined the relationship between morbidity measures and opioid prescribing at hospital discharge using multivariate regression analysis.
Results: The mean age was 75 ± 8 years, 57% were female and 50% were non-White. Mean CIRS-G total score was 17 ± 6, indicating high cumulative illness burden. Ninety-nine percent of patients had multimorbidity, defined as moderate-to-extremely severe morbidity in =2 organ systems. Sixty percent of patients received an opioid prescription at discharge. In multivariate analyses adjusted for age, race, and gender, patients with a discharge opioid prescription were significantly more likely to have higher cumulative illness burden and chronic pain.
Conclusion: Among older medical inpatients, multimorbidity was nearly universal, and patients with higher cumulative illness burden were more likely to receive a discharge opioid prescription. More studies of benefits and harms of analgesic treatments in older adults with multimorbidity are needed to guide clinical practice.
The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty.
The 2016 Colorado End-of-Life Options Act includes a provision unique among states with such laws, specifically privileging individual health care professionals, including physicians and pharmacists, to choose whether to write and fill prescriptions for life-ending medications, such as high-dose secobarbital or various combinations of morphine, diazepam, beta-blockers, and digoxin, without regard to the position their employer has taken on the law. This provision virtually guaranteed the Colorado law would eventually be challenged, which happened in August 2019. The current legal case directly pits the conscience rights of individual health care professionals against those of religiously affiliated corporations. Because 5 of the top 10 US hospital systems by net revenue are now religiously affiliated, and these systems often restrict medical care in a variety of ways, how the case is resolved could have far-reaching implications for US health care, extending well beyond the relatively rare use of aid-in-dying medications at the end of life.
Background: Black cancer patients experience pain. Barriers to opioid medications for pain may include geographic factors. This study examines neighborhood factors associated with difficulties receiving prescription opioids from pharmacies for black cancer patients.
Design: A secondary data analysis of a study on opioid adherence was used to examine neighborhood-level and individual factors related to difficulties filling prescriptions for opioids.
Setting/Subjects: Patients being treated for cancer pain with opioids (n = 104) were recruited. All self-identified as black, were 21 years or older, had cancer diagnoses, and had been prescribed extended release opioids.
Measurements: A seven-item survey to identify problems filling opioids was completed by 98 participants along with a nine-item scale to assess perceived neighborhood characteristics. Scales of neighborhood amenities and neglect were created from the perceived neighborhood characteristics scale using principal components analysis. The 2009–2013 American Community Survey data were used to estimate the census tract percentage of non-Hispanic black residents, residents =25 years of age without a high school degree or equivalent, and households earning below the federal poverty level within the past 12 months.
Results: Nearly 51% reported problems getting their opioids filled: 28% had to wait days and 24% had to return to the pharmacy multiple times. The main theme identified in analysis of an open-ended question was pharmacies not stocking medication. Neighborhood locations that rated higher on the amenities scale were protective for pharmacies sufficiently stocking opioids.
Conclusions: Additional research on pharmacies sufficiently stocking opioid pain and neighborhood perceptions is warranted.
The aim of deprescribing in end-of-life care is to improve the patient's quality of life by reducing their drug burden. It is essential to engage the patients and enable them to make choices about medications by discussing their preferences and implement a pharmacy management plan. Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially. The aim of this article is to address polypharmacy within end-of-life care. It will review which medications should be stopped by examining the non-essential and essential drugs. The intention is to encourage an approach to care which provides an equal balance between treatment and patient expectation.
The problem of opioid diversion and its contribution to the opioid epidemic are well known nationally, existing even within hospice care. Proper disposal of opioids may be a critical factor in reducing diversion. In 2014, Ohio implemented legislation requiring a hospice employee to destroy or witness disposal of all unused opioids within a patient’s plan of care. The purpose of this study was to determine the impact of Ohio Revised Code 3712.062 on hospice programs’ policies and procedures to prevent opioid diversion in the home. Directors of Ohio-licensed hospices were surveyed to assess the percentage of programs with a written policy in place for disposal of opioids and to calculate a compliance score based on responses to survey questions assessing compliance with legislation components. Fifty-two surveys were completed (39.4%). All survey respondents reported having a written policy in place. A 95.5% average compliance score was calculated, with the largest disparity occurring with timing of opioid disposal. While Ohio Revised Code 3712.062 requires opioid disposal at the time of patient’s death or when no longer needed by the patient, only 84% of respondents report disposing opioids upon discontinuation. Overall, a high compliance rate was seen among hospice programs indicating such regulation is manageable to meet.
BACKGROUND: Antimicrobial treatment is common at end of life. A treatment escalation/limitation plan (TELP) offers the opportunity to avoid non-beneficial treatment in critically ill patients. Our aim was to evaluate antimicrobial prescribing in terminally ill patients, and assess whether it was modified using a TELP.
METHODS: Appropriateness of antimicrobial treatment was audited using a priori criteria in 94 consecutive hospital deaths. Prescribing in patients whose death was expected/unexpected, and who had a TELP with/without a 'ceiling' for antimicrobials, were compared.
RESULTS: Twenty three of 94 patients (24.5%) were receiving antimicrobials at time of death. This was not influenced by evidence of infection or whether death was expected. The use of a TELP (n = 81) with an antimicrobial 'ceiling' (28 with, 53 without) was associated with a significant reduction in antimicrobials administered (28.6% vs 81.1%; p < 0.0005).
CONCLUSIONS: Many complex factors contribute to antimicrobial misuse at end of life. An appropriately constructed TELP reduces inappropriate prescribing.
AIMS: Older patients with life-limiting illness (LLI) and limited life expectancy (LLE) continue to receive potentially inappropriate medicines, consequently deprescribing is often necessary. However, deprescribing in this population can be complex and challenging. Therefore, we aimed to investigate the evidence for outcomes of deprescribing interventions in older patients with LLI and LLE.
METHODS: Studies on deprescribing intervention and their outcomes in age =65 years with LLI and LLE were searched using PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Google Scholar. Medication appropriateness was primary outcome, while clinical and cost-related outcomes were secondary. Eligibility, data extraction and quality assessment were followed by a narrative synthesis of data.
RESULTS: Of nine studies (1371 participants), three reported on primary outcome. One study showed a significant reduction in medication inappropriateness by 34.9% (p<0.001) from admission to close-out, the second achieved 29.4% (p<0.001) and 15.1% (p=0.003) reduction at 12 and 24 months respectively. The third reported that their intervention stopped (17.2%) and altered the dose (2.6%) of high risk medications. Commonly reported clinical outcomes were mortality (n=3), quality of life (n=2) and falls (n=2). Outcomes in terms of cost were reported as overall cost (n=2), medication cost (n=1) and health care expenditure (n=1).
CONCLUSIONS: Our findings suggest that deprescribing in older patients with LLI and LLE can improve medication appropriateness, and has potential for enhancement of several clinical outcomes and cost savings, but the evidence needs to be better established.
Background: Off-label-use is an indispensable element of palliative medicine. Up to one third of all drugs are prescribed beyond their licence. It is challenging to find the right balance between potential risks and benefits in the context of limited therapeutic options. To date, little is known how physicians deal with this challenge in daily practice.
Objectives: To evaluate (1) the awareness of German palliative medicine physicians of off-label-use, (2) the basis for decision-making for off-label-use, (3) the existence of guidelines for off-label prescribing and (4) practical problems arising in clinical practice.
Methods: Anonymous online survey among German palliative medicine physicians. Medical directors and consultants/other doctors were surveyed independently with two different questionnaires. The questionnaires included questions regarding documentation, legal and practical aspects of off-label drug use.
Results: In total, 578/605 emails sent were delivered. One hundred and forty-one questionnaires were fully completed, 8 partially. Response rate 23%. The majority of participants worked in specialist palliative home care and palliative care units (n = 134). One hundred and two (68%) participants were aged >50 years and 103 (69%) practised medicine >20 years. One hundred and twelve medical directors participated, 95 (85%) reported that no guidance on documentation of off-label-use was available. In total, 30/37 consultants and other doctors indicated experience as basis for their decision making on off-label-use. Twenty-four (75%) of the consultants and other doctors regularly used off-label-therapies with little or no evidence base. Uncertainties exist regarding drug safety, legal issues and the cost coverage.
Conclusions: More recommendations on the management of off-label drug use are necessary. Participants demand greater legal security including unbureaucratic prescribing.
Nurses who care for patients with life-limiting illness operate at the interface of family caregivers (FCGs), patients, and prescribers and are uniquely positioned to guide late-life medication management, including challenging discussions about deprescribing. The study objective was to describe nurses’ perspectives about their role in hospice FCG medication management. Content analysis was used to analyze qualitative interviews with nurses from a parent study exploring views on medication management and deprescribing for advanced cancer patients. Ten home and inpatient hospice nurses, drawn from 3 hospice agencies and their referring hospital systems in New England, were asked to describe current practices of medication management and deprescribing and to evaluate a pilot tool to standardize hospice medication review. Analysis of the 10 interviews revealed that hospice nurses are receptive to a standardized approach for comprehensive medication review upon hospice transition and responded favorably to opportunities to discuss medication discontinuation with FCGs and prescribers. Effective framing for discussions included focus on reducing harmful and nonessential medications and reducing caregiver burden. Results indicate that nurses who care for hospice-eligible and enrolled patients are willing to discuss deprescribing with FCGs and prescribers when conversations are framed around medication harms and their impact on quality of life.
BACKGROUND AND OBJECTIVES: Deprescribing may be particularly relevant in older people with limited life expectancy. In order to effectively carry out deprescribing in this population, it is important to understand the perspectives of the full spectrum of health care professionals (HCPs) involved in the management of these patients' medication. Thus, we aimed to explore different HCPs' perspectives on deprescribing in older patients with limited life expectancy.
RESEARCH DESIGN AND METHODS: Six qualitative focus group interviews were conducted using a semistructured approach. The groups comprised HCPs from both primary and secondary care, including family physicians (FPs), geriatricians, clinical pharmacologists, clinical pharmacists, nurses, and health care assistants. Interviews were audio recorded and transcribed verbatim. Results were analyzed using systematic text condensation.
RESULTS: A total of 32 HCPs participated in the study (median age of 40.5 years; 22% male). The analysis elicited three main themes related to HCPs' perspectives on deprescribing in older patients with limited life expectancy: (a) Approaching deprescribing, (b) Taking responsibility, and (c) Collaboration across professions. Within themes, subthemes were identified and analyzed.
DISCUSSION AND IMPLICATIONS: Our results imply that different groups of HCPs consider deprescribing an essential aspect of providing good care for older people with limited life expectancy and find that all HCPs play a crucial role in the deprescribing process, with FPs having the primary responsibility. In order to facilitate deprescribing among this population, however, the collaboration between different HCPs should be improved.
OBJECTIVE: To provide insight into the prescribing practices of three independent nurse prescribers (INPs)/clinical nurse specialists (CNSs) working in a supportive and palliative care team (SPCT) in a district general hospital and a specialist tertiary cancer centre in the UK.
METHODS: A prospective review of all consultations and the prescribing activity arising from the consultations (and reasons for non-prescribing following a consultation) of 3 INPs/CNSs between 1 August 2018 and 31 October 2018.
RESULTS: Four hundred ninety-three consultations were undertaken on 186 individual patients. Two hundred forty-seven consultations representing 50% resulted in changes to a prescription, and 123 of those consultations representing 50% of prescriptions written resulted in the prescribing of an opioid for moderate-to-severe pain.
CONCLUSIONS: This service evaluation demonstrates the potential for INPs in SPCTs to provide comprehensive symptom control while enabling CNSs to practice with a greater degree of autonomy leading to enhanced job satisfaction. On the basis of our experience, we would encourage all palliative care CNSs to undergo training to become INPs (if available).
Prescription opioids are among the most effective analgesics to treat moderate to severe pain; however, little is known about the use of prescription opioids in children, particularly those receiving an extended-release formulation for the treatment of chronic pain. In this retrospective study, the authors determined the prevalence of prescription opioid use among 7–17-year-old children and associated comorbid health conditions from 2010 to 2013 using Truven Health MarketScan (MarketScan) and Optum Clinformatics DataMart (Optum). The primary end points were prevalence of using any prescription opioids, using only prescription short-acting opioids (SAOs), and at least one prescription of a long-acting opioid (LAO). The prevalence of prescription opioid use among children is non-negligible and has been trending downwards: 6.90% in 2010 and 5.93% in 2013 using MarketScan and a similar trend using Optum: 5.47% in 2010 and 4.51% in 2013. Very few children had claims for LAOs, with only 0.04% (4979 children) in MarketScan and 0.03% (1117 children) in Optum. Given the very small number of children, primarily in the 12–17 age group, who are prescribed LAOs, there is a need to focus on a better understanding of the patterns of SAO use in children.
An increasing number of jurisdictions allow individuals to obtain medication prescribed by their physicians for medical assistance in dying (MAID). But discussion of whether (and to what extent) individuals have the right to use the health care system to control the time and manner of their death is not limited to MAID. The right also exists in other contexts, such as directing the withdrawal of life-sustaining treatments. Palliative (or terminal) sedation involves medications to render a patient unconscious, coupled with either the withdrawal of artificial nutrition and hydration or their not being administered at all. In high-enough doses, these medications may further suppress already-weakened cardiopulmonary function even if there is no intent to hasten death. When teaching about these topics, I challenge students to consider whether there are meaningful differences between practices like euthanasia, MAID, aggressive use of morphine, terminal sedation, or the withdrawal of ventilator support. Whether their differences are morally, ethically, or legally meaningful can be difficult to tease out. After recently watching a loved one, whom I call "Stephan," direct the time and manner of his death within hospice care in a state that does not allow MAID, I am less inclined than ever to believe that the differences are meaningful in a way the law should recognize.
The use of multiple medications is common in palliative care, putting patients at risk of adverse events and a high tablet burden. Deprescribing is the process of reviewing and stopping potentially inappropriate medications in order to improve quality of life. Barriers to deprescribing exist meaning many patients will take multiple medications despite being in the final months of life. The OncPal deprescribing guideline is a useful tool to support the process for patients with a limited life expectancy. There is evidence for the safety of stopping certain medications, particularly those aimed at primary prevention. A systematic process of reviewing individual medications and their appropriateness is recommended.
Background: The most important decision after diagnosing terminal cancer is whether to provide active therapy or withhold treatment.
Objective: To analyze the aggressiveness of care by evaluating systemic anticancer therapy (SACT) given near to death, describing this care and identifying factors that determine its use.
Design: This involves retrospective observational cohorts study.
Setting/Subjects: This involves patients with metastatic tumors who died at a University Hospital in Spain between 2015 and 2016.
Measurements: Data obtained from prescribing oncologists and patients' clinical records, type of cancer, and information on treatment. The dependent variable used was the interval between the date of the last dose and date of death.
Results: Ninety-four (32.60%) of 288 patients received SACT in the last month of life. This cohort had a higher frequency of lung cancer (OR: 1.58; CI 95%: 1.14-2.18), received more care from oncologist 2 (OR: 1.50; CI 95%: 1.08-2.08), had fewer last-line treatment cycles (OR: 1.28; CI 95%: 1.13-1.45), a lower subjective response (OR: 3.13; CI 95%: 1.34-7.29), less clinical benefit (OR: 2.38; CI 95%: 1.04-5.55), more visits to the Emergency Department (OR: 1.59; CI 95%: 1.06-2.38), and less care from the Palliative Care Unit (OR: 4.55; CI 95%: 2.69-7.70). In multivariate analysis, the predictors of having received SACT close to death remained: receiving fewer cycles of treatment (OR: 1.28; CI 95%: 1.12-1.47) and less palliative care (OR: 4.54; CI 95%: 2.56-7.69).
Conclusions: A third of cancer patients received SACT in the last month of life with less efficacy and poorer quality of care than patients not receiving it.
OBJECTIVES: Out-of-hours (OOH) primary care services are contacted in the last 4 weeks of life by nearly 30% of all patients who die, but OOH palliative prescribing remains poorly understood. Our understanding of prescribing demand has previously been limited by difficulties identifying palliative patients seen OOH. This study examines the volume and type of prescriptions issued by OOH services at the end of life.
METHODS: A retrospective cohort study was performed by linking a database of Oxfordshire OOH service contacts over a year with national mortality data, identifying patients who died within 30 days of OOH contact. Demographic, service and prescribing data were analysed.
RESULTS: A prescription is issued at 14.2% of contacts in the 30 days prior to death, compared with 29.9% of other contacts. The most common prescriptions were antibiotics (22.2%) and strong opioids (19%). 41.8% of prescriptions are for subcutaneously administered medication. Patients who were prescribed a syringe driver medication made twice as many OOH contacts in the 30 days prior to death compared with those who were not.
CONCLUSION: Absolute and relative prescribing rates are low in the 30 days prior to death. Further research is required to understand what occurs at these non-prescribing end of life contacts to inform how OOH provision can best meet the needs of dying patients. Overall, relatively few patients are prescribed strong opioids or syringe drivers. When a syringe driver medication is prescribed this may help identify patients likely to be in need of further support from the service.
Background: Responding to an epidemic of opioid-related deaths, guidelines and laws have been implemented to promote safe opioid prescribing practices.
Objective: This study evaluates differences in screening practices and knowledge of laws between oncologists and cardiologists who prescribe opiates.
Design: Surveys regarding screening practices and knowledge of opioid prescribing laws were distributed in March 2017 to oncology and congestive heart failure (CHF) clinicians at the University of Virginia. Chi-square and Wilcoxon rank sum tests were used.
Results: Forty-six of 129 (35.6%) oncology providers and 7 of 14 (50%) CHF providers reported prescribing opiates in their clinic with usable survey results. The majority of oncology (65.22%) and cardiology (85.71%) providers report screening for substance abuse “when indicated” (p = 0.053). Only 19.6% of oncologists reported always using the prescription monitoring program (PMP), while 71.43% of cardiologists reported using it always (p = 0.014). Of the oncology providers, 66.67% report never using the urine drug screen (UDS), while 86.7% of cardiologists reported using it “when indicated” (p = 0.0086). Up to 34.78% of the oncologists and 57.14% of the cardiologists reported of never screening the family members for misuse (p = 0.317). Knowledge of laws was similar between groups, with 14.29% of cardiology and 17.39% of oncology providers reporting no knowledge of opioid prescribing laws (p = 0.2869).
Conclusions: Routine screening for substance misuse risk was uncommon for both groups, but cardiology providers were more likely to use the PMP or UDS. Knowledge gaps regarding Virginia laws were noted in both groups. Improved education regarding best practices and laws, as well as programs to promote screening, is needed for all providers.
Importance: The recent parenteral opioid shortage (POS) has potential implications for cancer-related pain management in hospitalized patients.
Objective: This study compared changes in opioid prescriptions and clinically improved pain (CIP) among patients treated by an inpatient palliative care (PC) team before and after our institution first reported the POS.
Design, Setting, and Participants: A cohort study of 386 eligible patients with cancer treated at a comprehensive cancer center 1 month before and after the announcement of the POS. We reviewed data from electronic health records, including patient demographics, opioid type, route of administration, and dose. Board-certified palliative care specialists assessed CIP at follow-up day 1.
Exposures: The announcement of the POS by the institution's pharmacy and therapeutics committee on February 8, 2018.
Main Outcomes and Measures: The primary outcome was to measure the change in opioid prescription patterns of physicians, and the secondary outcome was to measure the proportion of patients who achieved CIP before and after announcement of the POS.
Results: Of 386 eligible patients, 196 were men (51%), 270 were white (70%), and the median age was 58 years (interquartile range, 46-67 years). Parenteral opioids were prescribed less frequently by the referring oncology teams after the POS (56 of 314 [18%]) vs before the POS (109 of 311 [35%]) (P < .001). The PC team also prescribed fewer parenteral opioids after the POS (96 of 336 [29%]) vs before the POS (159 of 338 [47%]) (P < .001). After the POS (vs before the POS), significantly fewer patients achieved CIP on follow-up day 1 (119 [62%] vs 144 [75%] of 193; P = .01). Multivariate analysis showed that before the POS, patients had an 89% higher chance of achieving CIP on follow-up day 1 (odds ratio, 1.89; 95% CI, 1.22-2.94; P = .005).
Conclusions and Relevance: There was a significant change in opioid prescription patterns associated with the POS. Furthermore, after the POS, fewer patients achieved CIP. These factors have potential implications for patient satisfaction and hospital length of stay.