For End of Life Care, Less May Be More

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For End of Life Care, Less May Be More

By Neil Osterweil, Senior Associate Editor, MedPage Today Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine. March 27, 2006

ReviewCHICAGO, March 27 - Some physicians just can't seem to stop prescribing medications that carry risks for elderly patients who are past the point of achieving any benefit.

But a team at the University of Chicago hopes to change that by proposing prescribing guidelines that add to the usual risk-vs-benefit conundrum considerations about remaining life expectancy of the patient, goals of care, treatment targets, and time until treatment benefit.

"Physicians have clinical inertia with regard to prescribing, an idea that is just as applicable when considering the effort required to stop the use of medications as it is to the problem of under-use in the elderly," wrote geriatrician Holly M. Holmes, M.D., of the University of Chicago, and colleagues, in the March 27 issue of Archives of Internal Medicine.

The prescribing framework drew its motivation, Dr. Holmes said, from a fax sent by a pharmacy to the nursing home where she and her colleagues practice. The pharmacists had conducted a standard medication review of patients in the nursing home and pointed out that according to accepted guidelines, two of the patients should have been on statins and weren't.

"One of those patients was more than 100 years old, quite frail, with advanced cancer and multiple other medical problems," Dr. Holmes said. "The other one was dead. It made us wonder whether something wasn't missing from those guidelines." The guidelines that Dr. Holmes and colleagues proposed focus on appropriate prescribing for patients late in life, and are similar to those used to decide whether elderly patients should be screened for cancer. The first element of the guidelines was to weigh treatment against a patients' life expectancy. With the use of actuarial tables, prescribing physicians could calculate patients' remaining life expectancy and stratify them into percentiles modified by co-morbidities and patient history. "The healthiest 25% of people may live as long as the top 25th percentile, and those with multiple comorbidities, functional impairment, or disease-specific markers of poor prognosis may live a shorter time than the lowest 25th percentile," they wrote. A second consideration involved time to treatment benefit. The authors noted that analgesics provide an almost immediate benefit and can be particularly important for ameliorating pain in patients who are close to death, whereas other medications for, say, primary or secondary prevention may require months or even years of treatment before a therapeutic benefit can be achieved. It may be appropriate to withhold or withdraw drugs in such cases, the authors wrote. The third recommendation revolved around goals of care - moving targets as patients' age. "Regardless of standards of care, practice guidelines, and other clinical pathways, shared decision making among physicians, patients, and families about goals of care is important when deciding whether to stop, start, or continue therapy with a medicine for a patient late in life," Dr. Holmes and colleagues wrote. "As disease progresses and it is clearer that cure is not realistic, an individualized approach to a patient's treatment may become increasingly palliative."

Their fourth and final recommendation to physicians caring for elderly patients was to match the goals of care with treatment targets. Depending on the clinical situation and the wishes of patients and family, those targets may include palliation of symptoms, maintenance of current status, prolongation of life, prevention of morbidity and mortality, or treatment of acute illnesses. The authors acknowledged that stopping long-term medications in elderly patients, even when it's clinically appropriate, runs counter to physician exhortations to adhere to prescribed therapies. But when medication withdrawal or withholding is done properly and with the cooperation of patients and family, it can offer several advantages, said Caleb , M.D., a co-author. "Medication discontinuation, when done right, can decrease costs, simplify prescription regimens, decrease adverse drug events and focus therapy for maximum benefit," Dr. said.

http://www.medpagetoday.com/PrimaryCare/Geriatrics/dh/2939