Why are my medications stopped when I am on Hospice?
Many people have the misconception that going on hospice means all their medications will be discontinued. It is not a requirement that all medications be discontinued with the start of hospice care and it is not a goal of hospice care. Our goal is to make sure all medications are appropriate, effective, safe and a continued benefit for each person. This approach also involves the process of identifying medications in instances where potential harms outweigh existing potential benefits and where the treatment becomes more burdensome than the disease. It is often during this time near the end of life when a flip in the risk and benefit of many medications occur.
Medications are prescribed for disease treatment and for prevention benefit to prevent a future event such as a heart attack or stroke. In hospice care, the medication focus changes to control active disease and symptoms, maintain quality of life and provide comfort near end of life. Many factors are considered with appropriate medication therapy such as: drug- drug interactions, medication side effects, drug-disease interactions, appropriate dose, effect of age, risk of medication, total number of medications, medication pill burden, length of treatment with a medication and length of time to reach a benefit. Body processes are changing and the kidney and liver systems that help to eliminate medications may be affected by aging and by disease. Medication doses will often need to be adjusted or possibly discontinued to ensure continued safety. Examples of medications that reach most benefit with years of use and are preventive therapy are osteoporosis medications and cholesterol lowering medications. Stopping these medications during hospice care has not shown to be a harm to patients and in fact has shown to improve quality of life.2 Treatment of diabetes type II is another area where the long term control of blood glucose provides most of the benefit in prevention of small and large vessel disease in the body. Diabetes type II goals change at end of life and shift to a less stringent goal to reduce lows and highs of blood glucose. The American Diabetes Association loosens goals of A1C to equal or less than 8.5 at end of life which is an average blood glucose values of 195 mg/dl.
10 Drugs to Reconsider in Hospice Care. 1
Anticoagulants (warfarin; dabigatran; apixaban; etc)
Clopidogrel (unless indication for 2 antiplatelets)
Supplements and Vitamins
Antihistamines as often cause delirium
Diabetic treatment medications
Osteoporosis treatment medications
Appetite stimulants; megestrol
Inhalers changed to nebulizer solution
Anticoagulants are medications of preventive therapy for risk of stroke associated with non-valvular atrial fibrillation or blood clots from cancer or other conditions. The potential for bleeding or hemorrhage is often increased at end of life due to many factors and the risk of this therapy is often far greater than any preventive benefit. Example: A person who is on warfarin for atrial fibrillation will be at increased risk for adverse effects at end of life. As the patient declines, the INR may become difficult to regulate, the risk of falling increases and a problematic bleed can result. The hospice nurse discusses the risk and benefits of continuing warfarin with the interdisciplinary team. Knowing evidence-based information regarding stroke risk from atrial fibrillation without anticoagulation therapy is essential to balancing these therapeutic benefits and risk. If antiplatelet therapy is necessary, considering a change to aspirin may be an option for the patient to lower the risk of bleeding and eliminate INR monitoring and lab draws. 3
The process of ensuring medication safety is not a one size fits all. Changes in medication therapy must be done on an individual basis, weighing the risks and the benefits of each medication for each patient in their current disease state and health status and must also include the patient and family’s goals of care. 1
1. Allen R. 10 Drugs to Reconsider. NHPCO NewsLine.
2. McPherson M, Talebreza S. Discontinuing Medications Appropriately
3. Stsor Collier, Kyna, et al. “Medication Appropriateness at End of Life: A New Tool for …” Home Healthcare Nurse, Oct. 2013, journals.lww.com/homehealthcarenurseonline/Fulltext/2013/10000/Medication_Appropriateness_at_End_of_Life__A_New.10.aspx.