Deprescribing is the process of removing potentially inappropriate or unnecessary medications (Reeve et al, 2017). Non-adherence, lack of efficacy, actual or potential adverse drug reactions, the development of a contraindication, a request from a patient and researching the end of life are all reasons for discontinuing drugs (Reeve et al, 2013).
For non-medical prescribers (NMPs), it is important to consider deprescribing within all elements of their practice in an attempt to reduce pill burden and the subsequent ramifications of polypharmacy, with the aim of improving patient outcomes and care. Withdrawing medication during the end stages of life is extremely complex because the period of care varies substantially. Withdrawing too soon may be perceived as negligent and causing potential harm, but withdrawing too late would result in unnecessary treatment and subjecting the patient to the unnecessary stress of taking the medication (Duerdon et al, 2013). In palliative care, the median number of days of deprescribing any medication was found to be 4 days before death (Dore et al, 2019). The study broke it down further and found that 15% of medications were stopped due to swallowing difficulties, 17% due to rationalising medications and 56% due to approaching end of life. McNeil et al (2016) demonstrated that patients enrolled in their study took an average of 11.5 medications when joining the study and 10.7 at death or study termination.
Community NMP advance nurse practitioners can take on a vital role in the facilitation of timely deprescribing because they are actively involved in both long-term conditions and frailty management. The relationships established while caring for these patients allow discussions to take place regarding medication withdrawal as the disease process progresses.
Why stop medications?
Awareness of the anatomical changes that occur during the end stages of life is fundamental to supporting the rationale for stopping medications (Mangoni and Jackson, 2003). When a disease progresses, the body's metabolism changes and organs deteriorate and fail, thus altering both the pharmacodynamics (how a drug affects an organism) and pharmacokinetics (how the organism affects the drug) of the treatment. Therefore, these changes increase the likelihood of drug-related toxicity, the potential for drug interactions and, ultimately, how the individual responds to the drugs (Reeve et al, 2013; Alldred, 2014).
Essentially, deprescribing within palliative care suggests that the individual no longer requires medications used to preserve life because they are dying and the drugs are of no further benefit. For this reason, discontinuing medications is a sensitive subject and often avoided because the clinician's action could be misinterpreted, provoking feelings of being ‘written off’, ‘that there is no hope’ and that everyone has ‘given up’ (Akinbolade et al, 2016).
All conversations within end-of-life care must be patient-centred and occur through all stages of the disease progression in line with advance care planning (Jansen et al, 2014; National Institute for Health and Care Excellence (NICE), 2015b). However, care can vary greatly in practice, and, from experience, the author's group stops the majority of drugs when an individual reaches the dying phase rather than addressing deprescribing earlier. Sadly, because of the short time-span between actually stopping medication and death, deprescribing often has minimal benefits to the patient (Dore et al, 2019). Some 20% of palliative cancer patients take a potentially inappropriate medication (Lindsay et al, 2014), which highlights the need to change our approach within endof-life care. Practioners must also be aware that deprescribing helps make end-of-life care more manageable at home by reducing complex medication regimes, which often involve carers and family members (prompting or actually administering the medication) (Thomas, 2004).
When should medications be stopped?
Timing is key when considering the withdrawal of medications within end-of-life care; the challenge is to know when to actually stop. Ideally, it should happen when an individual asks to discontinue any drugs rather than when the patient is no longer able to swallow or is unconscious because they are dying or in the terminal phase of life (Akinbolade et al, 2016).
Awareness of the physical changes that occur during the dying process is hugely beneficial for the individual and family. This prepares them for the fact that there may come a time when the patient cannot actually take the medication and, if appropriate, an alternative route of administration should be considered.
End-of-life care focuses on quality of life (including symptoms control) and advocates a holistic approach by including both the patient and those who matter to them in open honest communication (Thomas, 2004). The use of the Screening Tool of Older Person's Prescriptions (STOPP) is vital within any medication review because, not only does it assist health professionals in their decision-making with regard to deprescribing but it also ensures that the individual is always included in the process (Gallagher et al, 2008; NICE, 2015a; Lavan et al, 2017).
What medications should be stopped?
According to the Health Survey for England 2016 (NHS Digital, 2017), the most commonly prescribed medications are cholesterol-lowering statins, anti-hypertensives (ACE inhibitors) and analgesics. Within end-of-life medication management, drugs can be be divided into non-essential and essential groups.
Non-essential drugs
Non-essential drugs are prescribed to manage an underlying condition. When there is no chance of recovery, their action could consequently prolong the dying process or serve no therapeutic purpose (Ellershaw et al, 2003).
Statins are prescribed for the primary prevention of cardiovascular disease by reducing the risk of cardiac events. They do not provide any symptom relief and are, therefore, considered non-essential drugs within end-of-life prescribing (Todd et al, 2014). The question of the ‘risk:benefit’ ratio for statins has resulted in several studies confirming that statins are often inappropriately prescribed or continued for patients who have life-limiting illnesses (Holmes et al, 2015; Kutner et al, 2015).
Oral hypoglycaemics and insulin are regarded as non-essential drugs and are stopped when the patient becomes unable to swallow and cannot receive nutrition or medications via a different route. The aim of diabetes management within endof-life management is to avoid unnecessary testing or injections and prevent any diabetes-related emergencies (Wessex Palliative Physicians, 2014). Cardiac medications such as angiotensin-converting enzyme inhibitors (ACE) and beta-blockers are prescribed to maximise haemodynamic functions, reduce risk and prolong life in combination. Consequently, some provide symptom relief by reducing fluid retention and breathlessness. Deprescribing within this group of drugs is patient-specific and in line with other essential drugs. This tends to occur when the patient is unable to swallow or experiences side-effects resulting from changes in their metabolism, for example, dizziness from ACE toxicity (Braganza et al, 2017).
Anti-coagulants are prescribed to prevent and treat venous thromboembolism and for stroke prevention. Therefore, discontinuation of these drugs should be considered if the risk of bleeding within end-of-life management outweighs the risk of thromboembolism (Goncalves, 2018).
Other reasons for discontinuation should include a decline in liver function (warfarin) or a deterioration renal function (direct oral anti-coagulant (DOAG)). Within deprescribing, anti-coagulants are considered to be non-essential because the risk of bleeding within end-of-life care management outweighs the risk of thromboembolism (Goncalves, 2018). Discontinuation of vitamins, minerals and other over-the-counter drugs should also be considered, as they have no therapeutic value at this stage (Abel, 2013).
Essential drugs
Essential drugs are medications that manage symptoms, such as breathlessness, pain and nausea. When the patient is unable take medications orally, an alternative route of administration—a syringe driver, subcutaneous injection or patch—should be considered (NICE, 2015a). Additional drugs are often prescribed during end-of-life care, which adds to the challenges of medicines reconciliation. A thorough explanation as to why drugs are being added when other are being withdrawn minimises the potential for giving mixed messages to the patient and their carer (Penson and Fisher, 2003).
Conclusion
End-of-life care should always be patient-centred and include advance care planning when considering deprescribing to avoid misinterpretation of actions. The need for each medication, as well as the route and time of administration, should be regularly evaluated considering the benefit of risk versus symptom management (Scott and Le Couteur, 2015). The aim would be to improve patients' quality of life by reducing their drug burden (Scott et al, 2015), and to engage patients and enable them to make choices about medications, discuss their preferences and agree a prescribing contract.
A NMP must be aware of the potential barriers of deprescribing that are patient-specific. Frustratingly, the initiation of medicines is guideline-driven, but guidance regarding when it may be safe or appropriate to discontinue treatment is less prevalent.
It is imperative that discussions about medication management occur promptly and throughout the dying process, involving the patient at all times. These must also be tailored to meet individual needs. Ensuring constant patient involvement will, hopefully, result an equal balance between treatment and patient expectation.
Key Points
- Deprescribing is the removal of potentially inappropriate or unnecessary medications
- The NHS has been spending billions on unnecessary over-treatment, over-diagnosis and over-prescribing. Many people are within the end stages of their life require multiple medicines as part of their treatment plan
- Withdrawing medications during the end stages of life is extremely complex because the period of care varies substantially
- Non medical prescribers need to carefully consider the therapeutic benefits of continuing medication as well as the risks of deprescribing at the end of life.
CPD reflective questions
- How many drugs are your patients prescribed? What are the implications to that individual and the risks of polypharmacy?
- Ask how your patients feel about taking drugs within the end stages of life. Do they know what drugs they are taking and how/why they take them?
- Explore the use of advance care planning within your clinical environment and implement patient centred approach to end-of-life care.