Objectives. The Art of Identifying and Communicating Medication Changes in Hospice

Transcription

1 The Art of Identifying and Communicating Medication Changes in Hospice Terri Maxwell, PhD, APRN health.com Marisa Todd, PharmD, BCPS Objectives Recognize contributory factors to polypharmacy in hospice Identify classes of medications appropriate to target for discontinuation in patients at the end of life Using case based scenarios, describe communication tactics for discussing medication changes with patients, family members and prescribers 1

2 Overprescribing Linked to over diagnosis and the problem of overtreatment Increase risk of adverse drug events (ADEs): Medication errors Side effects Drug drug or drug disease interactions Nonadherence Cognitive impairment Mobility impairment and fall risk Nursing home placement Hospitalizations Mortality PLOS One (4): e doi: /journal. pone Deprescribing Systematic process of identifying and discontinuing drugs when existing or potential harms outweigh existing or potential benefits Performed within the context of the patient s care goals, current level of functioning, life expectancy, values and preferences Actual photo of one week s worth of medications before & after deprescribing (92 year old reduced meds from 9 to 2 due to concerns about side effects) David Alldred [@MedicinesDavid]. (2018, September 22). Deprescribing [Twitter moment]. Retrieved from: PLOS One (4): e doi: /journal. pone

3 Professional Barriers Difficulty deciding when and which medications to stop Few evidence based guidelines Concern about stopping medications started by other clinicians Pressure to adhere to prescribing guidelines Limited knowledge about stopping medicines Worry about medication withdrawal and fear of harming the patient Inertia it s harder to stop rather than start something Patient/Family Barriers Concerns about stopping medications My doctor said that I should take this the rest of my life. Fear of negative consequences Process for cessation is unclear Perception of abandonment Possible physical and/or psychological dependence PalliatMed Oct;20(10):

4 The Regulatory Imperative CMS memorandum of November 15, 2016, titled, Update on Part D Payment Responsibility for Drugs for Beneficiaries Enrolled in Medicare Key findings: Reiterated the need to improve coordinating coverage of hospicerelated drugs with Part D Sponsors: High number of maintenance drugs filed under Part D benefit after hospice election CMS is reviewing why maintenance drugs are not being coordinated and paid for by hospice beneficiaries Continues to be a focus of the Office of Inspector General (OIG) Retrieved from: Fee for Service Payment/Hospice/Downloads/ Part D Hospice Guidance.pdf The Opinion of CMS We continue to expect that hospices should be providing virtually all of the care needed by terminally ill individuals, including related prescription drugs. CMS states that it is rare for a drug not to be covered by hospice We will continue to conduct ongoing analysis of nonhospice spending during a hospice election and consider ways to address this issue through future regulatory and/or program integrity efforts, if needed. CMS 1692 P. p

5 Deprescribing Framework Less time Palliative More time Adapted from Holmes HM et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166(6): Curative Discontinuation Process Pharmacist/Reviewer performs a medication review with focus on drug indication Consider patient s goals, prognosis & risk of drug induced harm (i.e., age & # meds) Assess each medication s risk/benefit ratio, treatment target & time to benefit Identify and discontinue medications based upon priority Monitor the patient for effects Fast Facts and Concepts #321. Deprescribing. PCNOW. Published Sept

6 Key Medications to Evaluate for Deprescribing Antibiotics Appetite stimulants Anticoagulants Antihypertensives Diuretics (when used for hypertension) Dementia medications Diabetes medications Inhalers Proton pump inhibitors Statins Vitamins/supplements Fast Facts and Concepts #321. Deprescribing. PCNOW. Published Sept Communication Strategies The most effective discussions about deprescribing should be part of a larger conversation clarifying estimated prognosis and goals of care." Fast Facts and Concepts #321. Deprescribing. PCNOW. Published Sept

7 Communicating Recommendations Use a shared decision making model guided by the patient s goals of care Consider patient s diagnosis/prognosis, culture, beliefs & experience Example model: The SHARE Approach* Step 1: Seek your patient s participation Step 2: Help your patient explore & compare options Step 3: Assess your patient s values and preferences Step 4: Reach a decision with your patient Step 5: Evaluate your patient s decision *Agency for Healthcare Research and Quality (AHRQ). The SHARE Approach. Reviewed Aug Arch Intern Med. 2006;166(6): Communicating Recommendations Make a clear recommendation based upon the best available evidence Recommend alternatives Suggest gradual dose tapers or a time limited trial rather than abrupt discontinuation Remember that this is a process that may take time after trust has been established Focus on what hospice provides Arch Intern Med. 2006;166(6):

8 Tips on Timing Discussions On admission or prior to recertification During a family or facility care conference When it s time to re order a medication Changes in patient condition (i.e., patient is less responsive) or having difficulty swallowing Change in care setting or level of care Initiating the Discussion Patient/caregiver initiates: I m so tired of taking all of these medications. It s getting harder for Mom to swallow her pills. Do you have any suggestions? Health care professional initiates: We ll review your medications and then make recommendations about possible changes. We may add medications to help make you more comfortable and suggest stopping medications that are not helping you as much anymore. Your mom is taking a lot of medications; could we talk about some ways to simplify them? 8

9 Focus on Shared Goals What is most important to you and your mom right now? What are you hoping for? It sounds like it s hard for you to consider stopping your dad s dementia medication. Can I share what my experiences have been? I m worried that the large number of medications you are taking might put you at risk for falling; can we talk about reducing some of them? I see that you re having trouble swallowing your pills. Let s see if there are some medications that we can stop and others that we can get in a liquid form for you. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Hope Cambridge University Press. Finding the Right Words We want to decrease the chance of meds interacting with one another Are you comfortable with the idea of stopping some of your medications? Do you think that taking all of these medications is affecting your appetite? I m worried that your blood pressure has been running low, which could put you at risk for falling. I m going to discuss reducing or stopping your blood pressure medication with our medical director. Let s prioritize the medications that are essential to treat your symptoms. 9

10 Case Study: Mrs. Jones Mrs. Jones 96 years old Fast 7a dementia, comorbidities include osteoporosis and osteoarthritis Hospice Status: ENROLLED Mrs. Jones is currently residing in a nursing home and was admitted to hospice with a primary diagnosis of Fast 7a dementia. Her comorbidities include osteoporosis and osteoarthritis. She is having more difficulty swallowing and routinely refuses her medications. Her daughter visits weekly. Case Study: Medication Profile Donepezil (Aricept ) 10 mg PO daily for dementia Memantine (Namenda ) 10 mg PO twice daily for dementia Lidoderm 5% patch apply TOP up to 3 patches to painful area(s), once for up to 12 hours within a 24 hour period for pain Acetaminophen 325 mg PO q 4 hours for pain Alendronate (Fosamax ) 70 mg PO once weekly for bone health Calcium 600mg plus D (Caltrate ) 1 tablet PO twice daily for bone health Dulcolax 1 supp PR every other day PRN no bowel movement 10

11 Dementia Medications Indicated for patients functional enough to derive possible benefite.g. improvement in memory, awareness, and ability to perform daily functions In hospice eligible patients, dementia meds have no effect on improving or maintaining cognitive function or delaying disease progression Balance risk of harm compared to benefit Adverse effects such as nausea, vomiting, diarrhea, loss of appetite, weight loss, drowsiness, dizziness, etc. Recommend discontinuation by lowering the dose or tapering Case Study: Plan of Care IDT review and recommendations: Discontinue donepezil and memantine Discontinue alendronate and calcium/vitamin D Assess pain management with Lidoderm and acetaminophen for effectiveness 11

12 Dementia Meds: Sample Script Now that your mom is spending most of her time in bed, her dementia medication is not contributing to her comfort and may be causing side effects such as nausea and poor appetite. Let s slowly decrease it over the next few weeks while we carefully observe for any changes. Are you OK with that? Let s decrease the dose of Aricept and re evaluate your mother s condition over the next week. Case Study: Mrs. Smith Mrs. Smith 73 years old Severe COPD (FEV 1 =30), hypertension, depression and anxiety 30 pack year smoking history but stopped smoking 10 years ago Hospice Status: ENROLLED (3 weeks) Despite taking low dose morphine 3 4 times daily, she is experiencing frequent coughing productive of white sputum and severe breathlessness. She spends most of her time sitting in a chair or lying in bed and increasingly depends on her husband to help with her care due to her severe shortness of breath and fatigue. 12

13 Case Study: Medication Profile Tiotropium (Spiriva ) HandiHaler 18 mcg/cap DPI Inhale contents of 1 capsule once daily Budesonide formoterol (Symbicort ) mcg/puff MDI Inhale 2 puffs twice daily Morphine (Roxanol ) 0.5ml (10 mg) PO q 4 hours PRN shortness of breath Senna 1 tablet PO at bedtime to prevent constipation Lorazepam (Ativan ) 1 mg PO q 4 hours PRN anxiety Citalopram (Celexa ) 20 mg PO daily for depression Lisinopril (Zestril ) 20 mg PO daily for blood pressure Oxygen therapy 2L/min continuously via nasal cannula Inhaler Assessment MDI DPI Diskus Observe: 1. Breathe out fully through the mouth away from the inhaler before taking another breath 2. Before taking another breath, close mouth tightly around mouthpiece, press down on the canister (MDI) and take deep slow breath DPI s do not require manually coordinating with the inhaler, but they still need to take and hold a deep breath 13

14 Inhaler Assessment Assess patient use of a handheld inhaler and consider the following: Is patient frail and debilitated with poor inspiratory effort and/or unable to hold their breath for up to 10 seconds? Is patient unable to coordinate his/her breath when using the inhaler? Does patient have inadequate symptom relief with their inhaler? Does patient have cognitive impairment and/or unable to follow instructions? Does patient have decreased strength, or arthritis or joint pain in their hands? If the answer is YES to one or more, switching the patient from their MDI, DPI or soft mist inhaler to nebulized therapy is recommended Recommended Therapy for Dyspnea Nebulized treatments with albuterol, or albuterol with ipratropium,are good alternatives to handheld inhalers When initiating nebulized treatment, remember to discontinue handheld inhalers (duplicate therapy) Oral corticosteroids such as prednisone are more effective than inhaled corticosteroids & may also help appetite and fatigue Add morphine and/or an anxiolytic such as lorazepam when dyspnea is not managed by above 14

15 Case Study: Plan of Care After assessing Mrs. Smith s inhaler technique, it was decided that she may gain more benefit from her COPD drug regimen by changing from handheld inhalers to nebulized albuterol/ipratropium nebs Q.I.D. In addition, she is prescribed oral prednisone 20 mg PO daily to treat her COPD exacerbation Two days later, she is doing better and reports feeling less anxious and less short of breath Inhalers: Sample Script We often find that people with severe lung disease are not able to benefit as well from their inhalers like they once did. I d like to make some suggestions about changing your medications... Let s begin to address your shortness of breath by adding some low dose morphine to help your breathing before we make any changes to your pulmonary meds. Now that your breathing is easier with the morphine, I d like you to consider using nebulized medication instead of your Symbicort, since I think it will work better for you. How do you feel about my recommendation to stop your Symbicort and use your nebs more often instead? 15

16 Case Study: Mrs. Johnson Mrs. Johnson 92 years old HF (NYHA Class IV) Hx: HTN, CAD, CVA 10 years ago, hypothyroidism, gout Hospice Status: ENROLLED Mrs. Johnson is a 92 year old with end stage heart failure who is newly enrolled in hospice. She has resided in a nursing home for the past 3 years. Her medical history includes HTN, CAD, CVA 10 years ago, hypothyroidism and gout. Upon admission, it is noted that Mrs. Johnson is taking 12 medications. Case Study: Medication Profile Lisinopril (Zestril ) 20 mg PO daily for the heart Metoprolol succ (Toprol XL ) 50 mg PO twice daily for the heart Spironolactone (Aldactone ) 25 mg PO daily for the heart Furosemide (Lasix ) 40 mg PO daily for leg edema Clopidogrel (Plavix ) 75 mg PO daily to prevent blood clots Acetaminophen 2 tablets (650 mg) PO q 6 hours prn pain Calcium and Vit D 500 mg 400 units 1 tab PO twice daily for bone health Miralax 1 capful mixed with 8 oz water PO daily for constipation Atorvastatin (Lipitor ) 40 mg PO daily for cholesterol Levothyroxine (Synthroid ) 50 mcg PO daily for the thyroid Colchicine 0.6 mg PO daily PRN for gout flare up Alprazolam (Xanax ) 0.25 mg PO q 6 hours PRN for anxiety 16

17 Statins One of the most commonly used preventative medications for primary and secondary prevention of heart attacks and strokes Adverse effects are related to dose or drug interactions A randomized clinical trial* of discontinuing statin therapy in hospice patients suggested that cessation was not only safe, but improved quality of life Bottom line discontinue statins *JAMA Intern Med. 2015;175(5): Primary Health Tasmania. Statins: A guide to deprescribing. Published May Antiplatelet Therapy Patients who have undergone coronary stent procedures Dual antiplatelet therapy indicated for at least 12 months post stent placement Reevaluate use beyond 12 months post stent period due to risk of bleeding Patients often inadvertently left on aspirin and clopidogrel, especially in LTC Recommend discontinuing when no longer meets palliative care goals J Am Coll Cardiol 2016;68(10): doi: /j.jacc

18 Antiplatelet Therapy Secondary prevention of CV events/stroke prevention Increased risk of GI bleeding when clopidogrel is added to aspirin Risk of bleeding increases with age and other factors Discontinuation should be considered in patients with limited prognosis (they can be stopped without tapering) Primary Health Tasmania. Antiplatelet agents: A guide to deprescribing. Published May Antihypertensives Blood pressure decreases as a consequence of decreased food and fluid intake Tight BP control has only a long term benefit Risk of hypotension (falls, syncope, dizziness, fatigue) Can be safely discontinued in most patients Taper to prevent rebound hypertension Arch Intern Med. 2010;170(18):

19 Antihypertensives & Heart Failure Patients with Heart Failure will often continue their diseasespecific medications (i.e., ACEI, ARBs, Beta blockers, diuretics) until the burden of administration outweighs the benefit of symptom management Balance symptom management of disease (shortness of breath due and/or peripheral edema due to fluid overload) with potential low blood pressure when tapering therapy J Am Coll Cardiol. 2009;54(5): J Cardiac Fail. 2014; 20: J of Hosp and Pall Nursing. 2013;15(1): Fast Facts and Concepts #144: Palliative Care Issues in Heart Failure. Revised Jul Palliative care for patients with heart failure In: American College of Cardiology, Latest in Cardiology. Published Feb 11, Case Study: Plan of Care IDT review and recommendations: Discontinue atorvastatin Discontinue clopidogrel Discontinue calcium supplement Evaluate need for colchicine Evaluate levothyroxine* Consider tapering Lisinopril, Metoprolol, Spironolactone and Furosemide one at a time, when feasible, as tolerated *J Pain Symptom Manage Sept;52(3):e3 e4 19

20 Case Study: Mr. Delgado Mr. Delgado 62 years old Pancreatic cancer, DVT 4 weeks ago PPS 70 Hospice Status: ENROLLED (2 days) Admitted to hospice two days ago after deciding against further chemo when his CT showed worsening liver metastases. He is currently receiving Enoxaparin (Lovenox ) for his DVT. Despite 4/10 pain, he is still independent in all ADLs and goes for daily walks with his wife. Case Study: Medication Profile Morphine (Roxanol ) 1ml (20 mg) PO q 4 hours PRN pain Morphine SR (MS Contin ) 100 mg PO q 12 hours for pain Gabapentin (Neurontin ) 800 mg PO every 8 hours for pain Dexamethasone (Decadron ) 8 mg PO twice daily for appetite & pain Lorazepam (Ativan ) 1 mg PO every 4 hours PRN anxiety Enoxaparin (Lovenox ) 80 mg SQ every 12 hours to prevent clots Ondansetron (Zofran ) 4 mg PO every 8 hours for nausea Omeprazole (Prilosec ) 20 mg PO daily for the stomach Lipase 6000 units (Creon ) 2 capsules PO with meals and 1 capsule PO with snacks 20

21 Anticoagulant Therapy Examples of Agents Vitamin K antagonist Warfarin (Coumadin, Jantoven ) Direct Oral Anticoagulants (DOACs) Dabigatran (Pradaxa ) Rivaroxaban (Xarelto ) Apixaban (Eliquis ) Unfractionated Heparin Low Molecular Weight Heparins (LMWHs) Enoxaparin (Lovenox ) Dalteparin (Fragmin ) Fondaparinux (Arixtra ) Anticoagulant Therapy Patients in hospice and palliative care are at increased risk for VTE, however, incidence is low Lack of supporting evidence in those with short prognoses Considerations: Indication for anticoagulation Duration of therapy Risks of continuing anticoagulation Anticoagulate or treat symptomatically? Continue current agent or utilize most cost effective option? Fast Facts and Concepts #236. Pharmacologic treatment of acute venous thromboembolism in patients with advanced cancer. December

22 Anticoagulant Therapy Enoxaparin is the preferred agent to treat cancer VTE May be withheld or discontinued in patients receiving hospice care for whom anticoagulation is of uncertain benefit Very limited life expectancy with no palliative or symptom reduction benefit Asymptomatic thrombosis with concomitant high risk of serious bleeding Chest. 2016;149(2): Benefits Risks of ADR Case Study: Plan of Care After assessing Mr. Delgado s history of DVT and conferring with your hospice medical director, it was recommended that Mr. Delgado should continue enoxaparin until his condition deteriorates 22

23 Case Study: Mr. Wilson Mr. Wilson 88 years old HF (NYHA Class IV), renal failure, Type 1 diabetes, osteoarthritis, macular degeneration Hospice Status: ENROLLED (8 weeks) Mr. Wilson was admitted to hospice approximately 8 weeks ago. He lives with his wife. His condition is deteriorating. He spends most of the time in his recliner, his appetite is poor, he s losing weight and is dyspneic at rest. His losartan and carvedilol therapies were recently reduced and ultimately discontinued as his blood pressure has been low. He is receiving daily insulin injections (glucose 150 mg/dl, 1 month ago). He has been on a PPI for the past 2 years after receiving a prescription upon discharge from the hospital for a CHF exacerbation. Case Study: Medication Profile Morphine (Roxanol ) 0.5ml (10 mg) PO q 4 hours PRN pain or shortness of breath Lorazepam (Ativan ) 0.5ml (1 mg) PO q 4 hours PRN anxiety Furosemide (Lasix ) 80 mg PO twice daily for fluid retention Escitalopram (Lexapro ) 20 mg PO daily for mood Lansoprazole (Prevacid ) 30 mg PO daily for the stomach Insulin glargine (Lantus ) 15 units SQ at bedtime for blood sugar 23

24 Proton Pump Inhibitors (PPIs) Indicated for the treatment and prevention of heartburn, ulcers and GERD Frequently prescribed indefinitely, even when no longer needed Risks include: Decreasing the body s defense against infections including link to C difficile diarrhea Block absorption of essential vitamins and minerals Long term use associated with increased risk of bone fractures Drug drug interactions Canadian Family Physician 2017;63(5): Primary Health Tasmania. Proton pump inhibitors: A guide to deprescribing. Published May PPIs in Hospice Evaluate if PPI is indicated: Ask the patient if he/she knows why and when the PPI was prescribed Weigh risks vs. benefits of continuing therapy; discontinue when there is no urgent indication Bottom line If PPI is indicated, guidelines suggest using the lowest effective dose of the least expensive drug for the shortest possible time Recommend Omeprazole (Prilosec ) 20 mg PO daily 24

25 Diabetes: Hospice vs. Non Hospice Non Hospice Tight glycemic control Goal of long term prevention of microvascular complications Benefit observed after many years of therapy Hospice Looser glycemic control to prevent hypoglycemia Increased likelihood of medication changes, disease state progression and/or oral intake variability affecting glucose Care goals may not include glucose testing or injections Important to educate all diabetic patients and their caregivers the signs & symptoms of hyperglycemia and hypoglycemia Diabetes: Prognosis & Glycemic Goals Advanced disease and relatively stable Several months to a year life expectancy Medication regimens may not change Hyperglycemia may not be a concern Target fasting glucose of 180 mg/dl J Palliat Med. 2011;14(1): Fast Facts and Concepts #258: Diabetes management at end of life. Published Jul

26 Diabetes: Prognosis & Glycemic Goals Impending death (i.e., organ failure, limited oral intake) Several weeks or less life expectancy Adjust medication regimens accordingly Recommend decreasing or stopping insulin and sulfonylurea meds Tailor insulin therapy to maintain fasting glucose > 180 mg/dl J Palliat Med. 2011;14(1): Fast Facts and Concepts #258: Diabetes management at end of life. Published Jul Diabetes: Prognosis & Glycemic Goals Actively dying (i.e., multiple organ system failures, end of life symptoms such as agonal respirations) Life expectancy usually hours to days Primary focus is patient comfort Type I diabetes: Target should be liberal (i.e., <360 mg/dl) and insulin continued only if patient is prone to diabetic ketoacidosis (DKA) Type II diabetes: All insulin and non insulin hypoglycemics should be stopped J Palliat Med. 2011;14(1): Fast Facts and Concepts #258: Diabetes management at end of life. Published Jul

27 Diabetes: Prognosis & Glycemic Goals 2016 Diabetes guideline from the American Diabetes Association (ADA) supports discontinuation of most agents for Type II diabetes Tight glucose control important for long term benefit but may place patients at risk at end of life, especially related to reduced intake Hyperglycemia in most cases are asymptomatic Adds to medication burden and need for laboratory/glucose monitoring Some medications (Metformin (Glucophage ), pioglitazone (Actos )) contraindicated in patients with organ failure Continue in patients with Type I diabetes or those with high PPS, reasonable intake, or symptomatic from hyperglycemia Diabetes Care 2016;39: Case Study: Plan of Care IDT review and recommendations: Discontinue lansoprazole Hold insulin glargine therapy; monitor for food intake improvement and symptoms of hyperglycemia restart at lower dose if warranted 27

28 Diabetes: Sample Script People with advanced disease and diabetes may not benefit from blood sugar lowering therapy like they once did you might now be at risk for low blood sugar. I d like to make some suggestions about how you can recognize and treat low blood sugar... I m worried that your blood sugar is running low and your eating habits are irregular. Let s consider changing some of your diabetes medications. It sounds like it s hard for you to consider stopping your diabetes medications. What are your main concerns? How do you feel about my recommendation to stop your Glucotrol? Deprescribing Best Practices Discuss the process for medication review with patients and families during admission Set an expectation that changes might be made Wait until trust is established before recommending changes; recognize drug discontinuation as a process, not an event Provide the reasons why you are making your recommendation; educate them on why you and your team believe this is best for them 28

29 Deprescribing Best Practices Use positive language: optimize, decrease harm, maximize benefit, limit pill burden, etc. Provide recommendations and choices During IDT meetings, share success stories and discuss challenges in communicating medication changes with patients and family members. Learn from and support each other. Discussion/Questions Contact Information: Marisa Todd, PharmD, BCPS 29

30 References Agency for Healthcare Research and Quality (AHRQ). The SHARE Approach. Reviewed Aug tools/shareddecisionmaking/index.html. Accessed Oct 9, Back, Arnold, Tulsky. Mastering Communication with Seriously Ill Patients: Balancing Honesty with Hope Cambridge University Press. Bain KT, Holmes HM, Beers MH, et al. Discontinuing medications: A novel approach for revising the prescribing stage of the medication use process. J Am Geriatr Soc. 2008;56(10): Bath C. Discontinuing statins near the end of life is safe, can reduce symptom burden, and is generally acceptable to patients. 10 Jul 2014;5(11). Available from: 10, 2014/discontinuing statins near the end of life is safe, can reduce symptom burden, and is generallyacceptable to patients.aspx Center for Medicare & Medicaid Services (CMS). Update on Part D Payment Responsibility for Drugs for Beneficiaries Enrolled in Medicare Hospice. Published Nov 15, Retrieved from: Fee for Service Payment/Hospice/Downloads/ Part D Hospice Guidance.pdf Center for Medicare & Medicaid Services (CMS). Proposed Rules (CMS 1692 P). Medicare Program; FY 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Federal Register. Published May 18, 2018;83(89): p Retrieved from: /medicare program fy 2019 hospice wage index and payment rate update andhospice quality reporting Currow DC, Stevenson JP, Abernethy AP, et al. Prescribing in palliative care as death approaches. J Am Geriatr Soc. 2007;55: Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care part II: Cachexia/anorexia and fatigue. J Palliat Med. 2006;9(2):409:421. Deprescribing.org. Deprescribing Guidelines and Algorithms guidelines algorithms/. Accessed Oct 8, Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors. Canadian Family Physician 2017;63(5): References Farrell B, Tsang C, Raman Wilms L, Irving H, Conklin J & Pottie J. What are priorities of deprescribing for elderly patients? Capturing the voice of practitioners: A modified Delphi process. PLOS One (4): e doi: /journal. pone Garfinkel, D & Mangin, D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Arch Intern Med. 2010;170(18): Goodlin SJ. Palliative Care in Congestive Heart Failure. J Am Coll Cardiol. 2009;54(5): Graves T, Hanlon JT, Schmader KE, et al. Adverse events after discontinuing medications in elderly outpatients. Arch Intern Med. 1997:157(19): Holmes HM, Hayley DC, Alexander GC, Sachs GA. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;166: Holmes HM, Todd A. Evidence based deprescribing of statins in patients with advanced illness. JAMA Intern Med. 2015;175(5): Joven MH. Should the Treatment of Hypothyroidism Be Withdrawn in Hospice Care? J Pain Symptom Manage Sept;52(3):e3 e4. Available from: (16) /pdf. Accessed Oct 8, Kutner JS, et al. Safety and benefit of discontinuing statin therapy in the setting of advanced, life limiting illness: A randomized clinical trial. JAMA Intern Med. 2015;175(5): Kearon C, et al. American College of Chest Physicians: Antithrombotic therapy for VTE disease: Chest guideline and expert panel report. Chest. 2016;149(2): Levine GN, Bates ER, Bittl JA, et al ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST elevation myocardial infarction, 2014 ACC/AHA guideline for the management of patients with non ST elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol 2016;68: ; Linsky A, Simon SR, Bokhour B. Patient perceptions of proactive medication discontinuation. Patient Educ Couns. 2014;

31 References Munshi MN, Florez H, Huang ES. Management of diabetes in long term care and skilled nursing facilities: A position statement of the American Diabetes Association. Diabetes Care 2016;39: Ngo, J and Holroyd Leduc. Systematic review of recent dementia practice guidelines. Age and Ageing. 2014;143. O Mahony D, O Connor MN. Pharmacotherapy at the end of life. Age and Ageing. 2011;40(f): Primary Health Tasmania. Deprescribing guides. Updated Sep 23, guides/. Accessed Oct 8, Pruskowski J. Fast Facts and Concepts #321. Deprescribing Sept. Available from: of fast fact 320 Reisfield GM, Wilson GR. Fast Facts and Concepts #144: Palliative Care Issues in Heart Failure. Revised Jul Russell, BJ, Rowett D, Abernathy, AP, et al. Prescribing for comorbid disease in a palliative population: Lipid lowering agents. J Pall Med. 2015; 8(4): Stevenson J, Abernethy AP, Miller C, Currow DC. Managing comorbidities in patients at the end of life. BMJ. 2004;329: Teuteberg JJ, Teuteberg W. Palliative care for patients with heart failure In: American College of Cardiology, Latest in Cardiology. Published Feb 11, in cardiology/articles/2016/02/11/08/02/palliative care for patients with heart failure. Accessed Sep 27, Tjia J, Briesacher BA, Peterson D, et al. Use of medications of questionable benefit in advanced dementia. JAMA Intern Med. 2014;174(11): Tija J, Kutner JS, Ritchie CS, et al. Perceptions of Statin Discontinuation among Patients with Life Limiting Illness. PalliatMed Oct;20(10): Wang KA, Camargo M, Veluswamy RR. Evidence based strategies to reduce polypharmacy: A review. OA Elderly Med. 2013;1(1):1 5. Wendling P. Prescription is futile: Medication burden remains high at end of life. Oncology Practice Digital Network. 10 Apr Available from view/prescription is futile medication burden remains high at end oflife/0ec4de0f02d8d15413a3eed28b70759c.html Whellan DJ, Goodlin SJ, Dickinson MG, et al. End of life care in patients with heart failure. J Cardiac Fail. 2014; 20: Wilson J, McMillan S. Symptoms experienced by heart failure patients in hospice care. J of Hosp and Pall Nursing. 2013;15(1): Winlow BT, Onysko MK, Stob CM, Hazlewood KA. Treatment of Alzheimer disease. Am Fam Physician. 2011;83(12): Wong MH, Stockler MR, Pavlakis N. Biphosphonates and other bone agents for breast cancer. Cochrane Database Syst Rev. 2012;2:CD