From a hospice pharmacy perspective, end of life care is really all about comfort and the palliation of symptoms. That shift in priority often comes with a de-escalation of medication, a practice called “deprescribing.”
The choice to deprescribe medications is one every pharmacy benefits manager should be prepared to support. Deprescribing offsets the potential harm to the patient’s quality of life caused by polypharmacy practices, which is defined as the prescription of as many as 5-10 pharmaceuticals to a single individual. During the last stage of a loved one's life, patient and family/caregiver goals switch to focus on side effects and increasing comfort.
In hospice pharmacy benefits management, deprescribing is increasingly common and particularly seen at times of transition during the patient’s care. At the transition to hospice, aggressive treatment of a particular illness is necessarily replaced with pain management and monitoring. Reducing the number of prescriptions and therefore eliminating any potentially resulting side effects can increase comfort as terminal illness progresses toward the end stage of disease.
When that day comes
When the day comes that a hospice practitioner makes a home visit and suggests that the medications a patient planned to take for the rest of his or her life are no longer needed, it’s a difficult conversation to hold at an already emotional time. Delta Care Rx provides its clients with tools to assist the nurse and caregiver with deprescribing discussions. These tools outline how to broach the topic of deprescribing with the patient from an evidence-based perspective. For example, certain pharmaceuticals may no longer be indicated due to the terminal prognosis, or in some cases one drug might be preferred over another due to side effect profile. Sometimes we can even use side effects to our advantage in hospice. For example, a medication that can improve mood might also help the patient sleep at night and improve their appetite
The business of deprescribing
In the hospice pharmacy world, there is a necessary spotlight on the overall "per patient day" cost of a patient’s care. Quite simply, fewer medications reduce the cost of care, and at times the benefits of deprescribing in relation to the comfort of the patient can be extensive.
The idea of deprescribing isn’t always popular. Direct to consumer advertisements of prescription medications is legal in the United States, and we’re exposed every time we go to the doctor, turn on the TV, open a magazine, or read a medical article. Patients often go to the doctor knowing what medications they want before they arrive. Over time, doctors continue to write prescriptions often unknowing what the patient may have already been prescribed by other practitioners
Unfortunately few guidelines and protocols exist for pharmacists and practitioners related to deprescribing. Future work in this regard needs to include discussions of end stage disease, side effect profiles, and how our approach to pharmacotherapy needs to be altered at end of life.
Michelle J. Mikus-Rachwal, Pharm D, is pharmacy manager at Delta Care Rx.