Deprescribing in palliative care

The aim of this hot topic is to promote active deprescribing of inappropriate medicines in individuals with a shortened life expectancy.

Palliative care is not limited to those with cancer and includes those living with and dying from any advanced, progressive incurable condition, for example end stage COPD, motor neurone disease, severe chronic heart failure. It focuses on addressing symptoms and helping people to live as well as possible until the end of their lives. The focus is on reducing medication burden and promoting person-centred discussions to enhance quality of life, adherence with essential medicines, and reduce the risk of adverse drug effects.³³⁵

For individuals with shortened life expectancy, there may be discrepancy between appropriateness of long-term medicines and their treatment goals. Consideration should be given to the length of time required to achieve the desired treatment outcomes and potential higher risk of adverse effects.

Polypharmacy is common in palliative care and individuals often have a high medication burden. Deprescribing of inappropriate medicines reduces the medication burden and promotes person-centred discussions to enhance quality of life.

Whilst many people welcome a reduction in medication burden, others may be concerned by it. It is important to acknowledge the fear and uncertainty that individuals and family/carers may experience when stopping a medication that they believe is necessary and that they had taken for chronic conditions.

Polypharmacy is common in palliative care. Individuals are often taking medicines for chronic conditions, in addition to treatments for symptom management. Medication reviews should be undertaken regularly to meet the changing needs of the individual, and to reduce potential harm from previously well tolerated medicines. Consider factors such as age, frailty, comorbidities, altered organ function and the number and types of medication taken. Deprescribing of medicines should be considered where appropriate.

After discussion and agreement with the individual and/or family/carers, any medicines that are not providing symptomatic benefit, are causing harm or are deemed no longer necessary should be stopped. This may include long-term prophylaxis medication such as statins and antihypertensives.³³⁶

The goal is to improve quality of life and reduce the burden of unnecessary treatments, particularly in the final months of life.

Replacement therapies should be continued, e.g. levothyroxine, hydrocortisone, except under specialist advice. Insulin must be maintained in type 1 diabetes to prevent diabetic ketoacidosis, however a change to a simpler regimen such as once daily basal insulin can be considered.

Certain medications will need to be withdrawn more cautiously (e.g. cardiac rate control medications, immunosuppression in organ transplant recipients, antidepressants, opioids, benzodiazepines) to avoid withdrawal effects.

The risks and benefits of each prescribed medication should be evaluated in the context of the individual’s overall health condition and the established goals of care. For example, the risk of continuing anticoagulation for atrial fibrillation needs to be balanced against the associated risk in malignancy that is prone to bleeding. There is often no right or wrong decision and an informed discussion with the individual and their family /caregivers should assess the risk and benefits.

The risk of aspiration associated with continuing medications when the oral route is compromised must be considered and evaluated. It may be possible to administer the medicine in an alternative form (e.g. patches) or via a different delivery route. It is common for medications to be administered by subcutaneous (SC) injection and by continuous subcutaneous infusion (CSCI) in palliative care. As most medication have no marketing authorisation for subcutaneous administration this constitutes off-label use.

The responsibility for prescribing under such circumstances lies with the prescriber, who should be able to justify and feel competent in using this medicine. The BNF provides guidance on prescribing in palliative care including the use of unlicensed or off-label medicines;³³⁶ further guidance on the prescribing unlicensed medicines is available from the General Medical Council. The Palliative Care Formulary also provides guidance on the prescribing of off-label and unlicensed medicines in palliative care.³³⁷

Deprescribing should be considered proactively as part of ongoing clinical care, rather than as a separate reactive process as a consequence of an individual’s illness or development of an adverse drug reaction.³³⁸

People nearing the end of life may be taking preventative medications for chronic illnesses, as well as others that are no longer appropriate. The change from curative to palliative therapy, with a focus on individual comfort, should translate into changes in prescribing.³³⁹

It is appropriate to consider deprescribing in the following individuals:

• with malignant prognosis of six months or less as per OncPal guideline inclusion criteria
• with chronic ill health who meet criteria outlined by the Supportive and Palliative Care Indicator Tool (SPICT), suggesting they are in the last 6-12 months of life
• with a suspected prognosis of 6-12 months or less and Clinical Frailty Score 8-9, (based on expert opinion).

Specific areas/situations where medication may need to be introduced or increased

New medication may be required for the management of disease complications and the palliation of symptoms. These can be experienced as the disease progresses and an individual nears the end of life, for example, pain control, hypercalcaemia, nausea and vomiting.

The Scottish Palliative Care Guidelines provide practical, evidence-based or best-practice guidance on a range of common clinical issues for both generalist and specialist providers of palliative care.¹⁵⁸

Does the person understand the outcomes of the review, including risk and benefits?

• A person-centred approach is deemed to be an essential component of deprescribing decision-making.
• The priorities of individuals and their family/carers should be recognised and included as part of the deprescribing process.
• Care should be taken to ensure that the language used is aligned with shared expectations and shared decisions between the individual and prescriber.

Is drug therapy tailored to the individual?

Prescribing should be tailored to the needs of the individual with appropriate steps taken to:

• simplify the medication regime
• continue those medications that are essential
• consider withdrawing those that no longer provide benefit

Agree the plan

• Individuals and their family/carers should continue to be involved in decisions regarding medication and goals of care.
• As death approaches, changes in care goals should be continuously and regularly evaluated, and appropriate changes to medication made.

• self-management/support tools
• decision aids

The SPICT tool can be used to help identify people with deteriorating health due to a serious illness, one or more health conditions (multimorbidity) or frailty in older age so they benefit from holistic assessment, future care planning (advance/anticipatory care planning) and palliative care.

• Supportive and Palliative Care Indicators Tool (SPICT-4ALL^TM)

The following resources offer guidance on deprescribing in individuals with a shortened life expectancy.

• The OncPal Deprescribing guideline
• The ASSIGN Score –cardiovascular risk score
• Benzodiazepine tapering tool
• Prescribing Guidance for Moderate to Severely Frail Patients
• Guideline for deprescribing in patients with a shortened life expectancy across NHS Lanarkshire