8/21/2015. Discontinuing Medications: Dialogues for Nurses, Physicians, Patients and Families. Disclosure. Objectives

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1 Discontinuing Medications: Dialogues for Nurses, Physicians, Patients and Families Piper Black, PharmD, BCPS Clinical Pharmacist HospiScript, a Catamaran Company 1 Disclosure I have no financial relationships with manufacturers of commercial products or services. The discussion will include the use of medications for off-label indications or routes of administration. 2 Objectives Identify principles of decision making about medication use in end of life care Describe strategies for communicating with patients, caregivers and healthcare providers about discontinuation of medications Review common therapeutic areas/medications that may be considered for discontinuation in end of life 3 1

2 Why is this Important? Medication risks may outweigh the benefits Lack of evidence to support continuation of therapy Therapeutic benefit is diminished Does not meet patient s goals of care Meeting Conditions of Participation requirements for Medicare Cost of therapy For patients and caregivers Hospice and patient Medicare hospice benefit 4 Discontinuing Medications in End of Life Parameters to consider Remaining life expectancy Time until benefit Goals of care Treatment targets 5 Evaluating Appropriate Prescribing for Patients 6 Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:

3 Discontinuation Barriers Fear of losing control Fear of losing hope Sense of abandonment Sense that hospice is changing medications without physician s knowledge Cultural concerns Beliefs Decision-maker 7 Mr. K: 86yo, ES COPD & Dementia Past medical history: end stage COPD, O2 dependent, end stage dementia, hypertension and tobacco use PPS of 30%, FAST score of 7d Patient is non-ambulatory and incontinent of bowel and bladder Uncontrolled symptoms include anxiety and dyspnea Current medications inlcude: donepezil, memantine, Senna-S, Spiriva, Advair, prednisone and lisinopril 8 When and How Do These Conversations Occur? Communicating with patients, families and other practitioners about letting go of medications 9 3

4 Planned Discussions At the time of admission When filling the patient s pillbox or ordering refills During an extended care facility s care conference Prior to recertification Whenever there is a change in location or Level of Care due to a change in patient condition Whenever there is a need to change medications due to patient condition Difficulty swallowing Decreased responsiveness 10 Windows of Opportunity Seizing the moment: He takes pills all day long. No wonder he doesn t have an appetite. Mom doesn t even say my name anymore. I m having to use my inhaler more often-sometimes every 2 hours. 11 Windows of Opportunity Creating the moment: You take a lot of medications. I wonder if some may be causing side effects? With so many medications, I wonder if you ever prioritize the ones that are most important and skip others. I wonder if it s difficult for you to think about discontinuing medications that your mother has taken for a long time. 12 4

5 How Do These Discussions Occur? Build Develop Patient Centered Care Understand Listen Inform 13 The BUILD Model B: Build a foundation of trust and respect. U: Understand what the patient and caregiver know about the medication and disease progression. I: Inform the patient and caregiver of evidence-based information. L: Listen to the patient s and caregiver s goals and expectations. D: Develop a Plan of Care in collaboration with the patient and caregiver. 14 B - Build A foundation of trust and respect with the patient and caregiver Goal: Affirm the patient and caregiver; listen more than talk Key phrases Thank you for taking the time to talk with me. You do a great job advocating for your mother. As you know, cancer doesn t just happen to the patient; it impacts the entire family. This must be very difficult for you. 15 5

6 U - Understand What the patient and caregiver know about the medication and disease process Goal: Learn the patient s and caregiver s understanding and expectations for the medications Key phrases What has your doctor told you about how this medicine works? What do you think your mother will look like when the medicine is no longer effective? How will you know it s time to stop or change the medicine? 16 I - Inform The patient and caregiver about appropriateness of medications Goal: Provide evidence-based information in a non-threatening, noncoercive way Key phrases Here s what we know about this medicine. As your disease progresses we will probably need to make some changes in your medications. What worked before may not work now. There are other medications that may be more helpful for you at this time. 17 L - Listen To the patient and caregiver as they share their goals and expectations Goal: Learn what is important to the patient/caregiver Key phrases How can hospice be of help to you at this time? We can t reverse or cure your disease, but there are many things we can do to provide comfort and quality-of-life. What does quality-of-life look like to you? Did your mother ever share her thoughts about what she would want if she had dementia? 18 6

7 D - Develop A plan of care in collaboration with the patient and family Goal: Empower the patient/caregiver to direct their care Key phrases Here are some choices: We can continue with the current medications and not make any changes, or we could decrease the donepezil and re-evaluate your mother s condition in one week. My job is not to make decisions for you, but to provide you with information so that you can make informed decisions. What questions do you have about what we ve talked about? We will work in collaboration with you and your doctor. He still guides your care." 19 BUILD Model : Physician Communications Collaboration with physician Trust as a skilled practitioner Both of you are doing the best for the patient Respect for the patient/physician relationship Affirm the physician s efforts, knowledge and commitment to the patient Evidence-based practices Ask questions in IDT Information on patient condition Paint a clear, succinct picture 20 Discontinuing Medications 21 Image via Google Images: 7

8 Identifying Medications to Discontinue Lack of evidence to be continued at end of life Vitamins Statins Bisphosphonates Lose efficacy/necessity as the disease progresses and goals change Dementia-related medications Pulmonary medications Anticoagulant medications Antidiabetic medications 22 Dementia Medications Typically patients have progressed beyond the point where dementia medications provide benefit when: Patient has declined rapidly despite therapy Patient is no longer able to regularly make their needs known and/or ambulate by themselves Patient can no longer complete activities of daily living (ADLs) without assistance Functional Assessment Staging (FAST) score has progressed to a 7b or greater 23 Dementia Medications Appropriateness of these medications should be evaluated routinely Discussions should include: Goals of care Perceived benefit of treatment Patient prognosis FAST score Eventual discontinuation when no longer beneficial 24 8

9 Dementia Medications What if there is resistance from family members? Try a trial of a decreased dose and monitor for changes in the patient s status or symptoms If no change or improvement witnessed with decreased dose, the medication is no longer providing benefit and could be discontinued Should you taper doses when discontinuing? May want to taper if possible If patient is not swallowing, it may be appropriate to stop abruptly 25 Applying the BUILD Model to Dementia BUILD It is great to see you again. You have done a wonderful job caring for your mother. I m sure it has been very difficult to see her decline. Can you tell me more about how she has been doing lately? 26 Applying the BUILD Model to Dementia Understand What do you think your mother will look like when the medicine is no longer effective? Inform End stage means being bedbound, not eating, and not able to verbalize her needs to you. It sounds like her dementia is continuing to progress even though she is taking donepezil. 27 9

10 Applying the BUILD Model to Dementia Listen How does that compare to what she was eating a month ago? Develop What are your thoughts about decreasing or discontinuing donepezil? 28 Pulmonary Medications Assess ability to properly use inhalers Inhaler technique Cognition Signs and symptoms of poor inhaler technique include: Thrush Pneumonia Exacerbation Increased medication utilization Bed bound Agitation/delirium 29 Pulmonary Medications Review of pulmonary medications 4 classes Beta-agonists Anticholinergics Anti-inflammatory Miscellaneous (theophylline, roflumilast) Duplications Combination products Side effects Overutilization of beta-agonists and anticholinergic medications Anxiety Dyspnea Rescue inhaler/nebulizer Dyspnea Anxiety 30 10

11 Pulmonary Medications What follows when inhalers are stopped? Alternative nebulized and oral medications Palliative management of dyspnea Medications Non-pharmacological 31 Mr. K: 86yo, ES COPD & Dementia Past medical history: end stage COPD, O2 dependent, end stage dementia, hypertension and tobacco use PPS of 30%, FAST score of 7d Patient is non-ambulatory and incontinent of bowel and bladder Uncontrolled symptoms include anxiety and dyspnea Current medications inlcude: donepezil, memantine, Senna-S, Spiriva, Advair, prednisone and lisinopril How can you use the BUILD Model to start a conversation about discontinuing or changing Mr. K s medications? 32 Anticoagulants Continue or Discontinue Indication Prognosis Route of administration Bleeding risk Nutritional status Appropriate monitoring Medication adherence Medication changes Patient/family preferences Will a new clot impair this patient s function or quality of life? Image via Google Images:

12 Anticoagulants Prepare the patient and family Discuss early Provide options in potential changes in therapy Educate on patient decline Decreased renal function Decreased nutritional intake Swallowing status Increased bleeding risk 34 Applying the BUILD Model to Anticoagulants Understand What did the doctor tell you about this medication? Inform As we decline, renal function declines, which affects dosing of some anticoagulants, nutritional intake decreases which affects vitamin K intake and alters INR, swallowing becomes more difficult and our bleeding risk actually increases. 35 Applying the BUILD Model to Anticoagulants Listen I am concerned that sister will have a blood clot if the medication is stopped. BUILD It can be difficult to see her decline. Stopping medications can be scary

13 Applying the BUILD Model to Anticoagulants Develop What are your thoughts about continuing aspirin to provide some anticoagulation, but stopping warfarin which will decrease the bleeding risk and need for finger pricks? 37 Antidiabetic Medications Blood sugars need not be held to less than mg/dl for patients near the end of life. Many clinicians set the threshold at 250mg/dL. Tight glycemic control near end-of-life carries the risk of hypoglycemic episodes especially with declining oral intake Managing blood sugar to mg/dL allows for lower doses or elimination of antidiabetic medication and reduces risk of hypoglycemia Sulfonylureas Insulin 38 Applying the BUILD Model to Antidiabetic Medications BUILD It sounds like this has been a very challenging time for you. Can you tell me more about how you have been doing lately? 39 13

14 Applying the BUILD Model to Antidiabetic Medications Understand How will you know when to stop or change medications? Inform Our team is concerned that low blood sugars may cause confusion, increase falls or other serious conditions while taking this medication. Higher blood sugars are acceptable in hospice. 40 Applying the BUILD Model to Antidiabetic Medications Listen Well, my doctor told me to take this medication every day so I won t have high sugars. Develop I spoke with your doctor and he is also concerned that you may experience low blood sugars, which are more dangerous than high blood sugars. He is okay with stopping your glipizide while continuing to monitor for blood sugars. 41 It is important to assess the perceived benefit from medications versus the risk of side effects and increased pill burden

15 Tapering Medications 43 Medications That May Need Tapering Antidepressants Antipsychotics Antiepileptics Parkinson s medications Antihypertensives Muscle relaxants 44 What If There s No Time to Taper? Be alert to side effects of abrupt withdrawal Rebound hypertension Tachycardia Agitation Seizures Pain, nausea, sweating Rely on supportive care and comfort meds Contact medical director or pharmacist if concerned 45 15

16 Patient Case TP is a 90yo female with hypertension (BP 152/82, HR 74), moderate dementia and debility. Which of the following medications would you begin discussing discontinuation first? (a) amlodipine 5mg po daily (b) Vitamin E (c) donepezil 10mg po qhs (d) metoprolol tartrate 25mg po bid 46 Evaluating Appropriate Prescribing for Patients 47 Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9 Key Points The BUILD Model is an effective communication tool for discussions with patients, families and physicians. Build, Understand, Inform, Listen and Develop! Medication profiles may contain medications that do not correlate with the plan of care, lack support for continued use in end of life or have risks that outweigh the benefits. A review of the medication profile should include patient s prognosis and goals of care and identification of a medication s time until benefit and treatment target

17 Questions? Piper Black, PharmD, BCPS Clinical Pharmacist HospiScript, an Optum Company 49 References & Further Readings Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166: Graham J. End-of-life medications draw more attention, greater scrutiny. JAMA. 2015;313: Lexi Comp Online, Lexi Drugs Online, Hudson, Ohio: Lexi Comp, Inc; November 2014 Silveria MJ, Kazanis AS, Shevrin MP. Statins in the last six months of life: a recognizable, life-limiting condition does not decrease their use. J Palliat Med. 2008;11(5): Winblad B, et al. Donepezil in patients with severe Alzheimer s disease: double-blind, parallel-group, placebo-controlled study. Lancet. 2006;367: Winblad B, Poritis N. Memantine in severe dementia: Results of the 9M BEST study (Benefit and efficacy in severely demented patients during treatment with memantine). Int J Geriatr Psychiatry. 1999;14: Qaseem A, Snow V, Cross Jr. JT, et al. Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2008;148: Weschules DJ, Maxwell TL, Shega JW. Acetylcholinesterase Inhibitor and N Methyl D Aspartic Acid Receptor Antagonist Use among Hospice Enrollees with a Primary Diagnosis of Dementia. J Palliat Med. 2008;11(5): Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in elderly patient with chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2011;68: End Stage COPD Guidance Document. Dublin, OH; HospiScript Services, Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18): doi: /archinternmed American College of Chest Physicians Evidence Based Clinical Practice Guidelines: Antithrombic therapy and prevention of thrombosis, 9th ed. Chest. 2012; 141(2_suppl), p7s 690s. Available from: Noble SIR, Nelson A, Finlay IG. Factors influencing hospice thromboprophylaxis policy: a qualitative study. Palliative medicine. 2008;22: Hill RR, Martinez KD, Delate T, et al. A descriptive evaluation of warfarin use in patients receiving hospice or palliative care services. J Thromb Thrombolysis. 2009;27: AACE Diabetes Care Plan Guidelines, Endocr Pract, 2011;17(Suppl 2). American Diabetes Association (2010). Position Statement: Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 33,Suppl 1, S5-S10. DOI: /diacare S5. 50 References & Further Readings Common oral medications that may need tapering. Pharmacists Letter 2008;24: Collier KS, Kimbrel JM, Protus BM. Medication Appropriateness at End of Life: A New Tool for Balancing Medicine and Communication for Optimal Outcomes the BUILD Model. Home Healthc Nurse. 2013;31(9): Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York: Cambridge University Press; Lautrette A, Darmon M, Megarbane B, et al. Communication strategy and brochure for relatives of dying patients in the ICU. N Engl J Med 2007;356: Jackson VA, Back AL. Teaching communication skills using role-play: and experience-based guide for educators. J Palliat Med 2011;14(6): US Admin on Aging. The art of active listening. Aging I&R/A Tips. Tip Sheet 1. National Aging Information & Referral Support Center Available from: Buckman R. Practical plans for difficult conversations in medicine: strategies that work best in breaking bad news. Baltimore, MD: Johns Hopkins Press; National Health System (NHS) Trust. Difficult conversations: guidelines for staff. King s Health Partners; Available from: Cramer C. How to have difficult conversations with patients, families. Oncology Nursing Society, 37 th Annual Congress. Available from: