Pharmacists Speak Out About Too Many Meds at End of Life

Excellent article that addresses what I frequently encounter as an RN Patient Advocate. Key points are to talk to patients about their medication goals, assess medication appropriateness on a regular basis, engage pharmacists to do comprehensive medication reviews, and consider the appropriateness of “deprescibing”, with the communication skills needed to address all of these issues.

Too Many Drugs Too Close to the End?

Older adults often receive drugs that can be of questionable benefit during their last months of life, according to a large study that looked at the end-of-life medications prescribed across an entire nation.

Clinical guidelines that support health care providers when they face the decision to continue or discontinue medications near the end of life are sorely needed, the researchers said (Am J Med 2017 Apr 25. [Epub ahead of print]).

Among older adults, polypharmacy has become commonplace. In high-income countries, an estimated 25% to 40% of those aged 65 years or older are prescribed at least five medications (Lancet 2012;380[9836]:37-43). This polypharmacy can lead to drug–drug interactions and serious adverse effects, according to lead author Lucas Morin, MS, of the Aging Research Center at Karolinska Institutet, in Stockholm.

The researchers identified more than 500,000 adults older than 65 years of age who died in Sweden between 2007 and 2013, and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. The characteristics of study participants at time of death were assessed through record linkage with the National Patient Register, the Social Services Register and the Swedish Education Register. This investigation did not consider over-the-counter medications.

They found that patients received more medications as death approached. The proportion of older adults exposed to at least 10 different prescription drugs rose from 30% to 47% over the course of the last year before death. Older adults who died from cancer and individuals living in institutions received a greater number of medications than those suffering from another condition or living in the community. The number of drugs increased more slowly for those living in an institution than in the community, however.

Sean M. Jeffery, PharmD, BCGP, FASCP, AGSF, a geriatric specialist, who was not part of the study, said he was not surprised by the results, which are applicable to the United States. “[The results] are generally consistent with the trends we see in prescribing here: Community-dwelling elderly use fewer meds than institutionalized elderly,” said Dr. Jeffery, who is the director of clinical pharmacy services of Integrated Care Partners, Hartford Healthcare, in Wethersfield, Conn. “The general categories of medications used are also fairly consistent with what you would see in the United States.”

However, just because it is more medication doesn’t mean that it is inappropriate medication, he reminded. “People use more medications in the last year of life, as they may be experiencing significantly worsening of symptoms that leads them to seek relief,” said Dr. Jeffery, who is also a clinical professor at the University of Connecticut School of Pharmacy, in Storrs.

However, the frequent continuation of long-term, preventive treatments probably is not needed in many cases. For instance, the researchers found that during their last month of life, a large proportion of older adults used platelet antiaggregants (45%), beta blockers (41%), angiotensin-converting enzyme inhibitors (21%), vasodilators (17%), statins (16%), calcium channel blockers (15%) or potassium-sparing agents (12%). Those who died of cancer saw the greatest increase in the number of prescription drugs, even when analgesics were excluded from the total count.

Dr. Jeffery said the prescribing shows that many clinicians have a difficult time predicting death, and therefore, might be reluctant to discontinue maintenance medications. The study also couldn’t capture the influence of family members on decisions regarding whether to withdraw medications. He added that singling out patients who were in hospice or receiving palliative care would have been helpful to see whether the same trends occurred in that population.

This is a role made for pharmacists, who can help clinicians decide when to discontinue unnecessary medications, as well as adjust needed medications based on the pharmacokinetics of the patient, he noted. “There is a growing push for deprescribing whereby clinicians would start the process of removing medications that are unwarranted, no longer aligned with the patients goals of care or are potentially harmful,” Dr. Jeffery explained.

However, the researchers noted that “the process of de-prescribing requires timely dialogue between the patient, family, and physician, and close monitoring of symptoms. It is also essential that patients and their relatives receive clear information about their options in terms of palliative care in order to counter the feeling of abandonment that they may experience when treatments are withdrawn.”

The researchers said polypharmacy during end-of-life care raises ethical questions about the potential futility of treatments close to death, citing issues such as increased adverse events.

“By continuing active treatments when death is likely, it creates a disconnect between the likelihood of death and the patients and families awareness that death is near,” said Dr. Jeffery, which could result in patients receiving treatments “that have no way of extending life but do incur potential harm, may hasten death and are still costly.”

The researchers suggested that clinical guidelines be developed to support practitioners in their effort to reduce potentially futile drug treatments near the end of life.

Until then, Dr. Jeffery suggested that pharmacists:

  • empower patients to talk about their medication goals of care;
  • perform an annual assessment of medication appropriateness;
  • engage Part D patients in comprehensive medication reviews; and
  • develop motivational interviewing skills to help patients with deprescribing.

A weakness of the study was that it did not include OTC medications, he added. “Don’t forget the OTC medications,” he said. “The number of medications people use and cycle through may be greater than expected.”

How An RN Patient Advocate Can Manage Post-Acute Care

Patients and families are frequently scared and confused about the post-acute plan of care. Unfortunately, poor communication within facilities, and across providers is often the rule, rather than the exception. Encourage patients and family members to engage a qualified, independent patient advocate to help them navigate the medical system, understand their options, and have choices in the care they receive.

5 keys to effective post-acute care management

Hospitals face increasing pressure to reduce readmission rates, and one way to accomplish that goal is to better align with post-acute care providers.

Effective post-acute care management requires a multidimensional approach that incorporates effective communication, data analytics and clearly defined care coordination roles, according to a new white paper from Leavitt Partners. The benefits, however, are clear, as better post-acute care management can reduce readmissions, allow providers to more easily manage length of stay in skilled nursing facilities and better monitor discharge.

Post-acute care is the “next frontier” for integrated delivery networks, health systems under payment risk, accountable care organizations, bundled payment awardees and MA plans, according to the report. “However, significant complexities exist on the road toward PAC integration.”

The report offers five “essentials” to building an effective post-acute care management program:

  1. Build strong relationships with post-acute providers. Effective teaming means sharing resources and accountability while building trust across different sites of care.
  2. Identify the right site of care first, and coordinate care better. Effective post-acute management plans can apply experience and historical data in tandem to find the correct solution earlier. Once patients are discharged, coordinated care can monitor medication adherence and offer home assessments for better outcomes.
  3. Embrace data analytics. Analytics is key to value-based care programs, according to the report, but for post-acute care, effective use of data can help providers determine the best site of care for patients and provide feedback to partners across the continuum.
  4. Engage patients, their families and caregivers. This is particularly important for high-risk patients who may be receiving home care, as the role of caregiver can be overwhelming.
  5. Use technology to foster communication. Remote monitoring and video visits can allow providers to track patients after discharge while avoiding unneeded, costly stays in skilled nursing facilities. A good care coordination team will also provide clear instructions patients can follow at discharge, according to the report.

Who’s Advocating for You at the End of Your Life?

Our medical system has huge end of life issues to deal with: everything from rapidly changing technology (for whom?), to delivering quality, palliative care.  Here’s what most people agree on: they don’t want to die in pain, they want to be in control of their care, be treated with respect and dignity, and die in their preferred place called home.

Pricey Technology Is Keeping People Alive Who Don’t Want to Live

Author: Jessica Zitter. Jessica Zitter Science

Whole-Person Well-Being is the Goal!

Since starting my RN Patient Advocacy practice in 2010, the goal for my patient-clients is for holistic health, and whole-person well-being.  This always includes consideration for the mental, emotional, spiritual, environmental, social, and physical aspects of their lives.  I use holistic health assessment tools, and encourage my clients to use the self-assessment tool that I provide for them.

How health and wellness transformed into well-being

Words matter. Over the past 60 years, we have changed the language describing our approach to health, wellness and well-being. At face value, this transition seems simple. We were first advised to seek “health” in the 1950s and then “wellness” in the ‘70s, ‘80s, and ‘90s. Now, we have moved on to “well-being.”

These terms evolved from the old notion of health as simply the absence of disease, to wellness as health and stress resilience. Ultimately, the term “well-being” now encompasses the broader social and environmental aspects of our lives.

It’s a nice story. But even in the late 1940s, the World Health Organization defined health as a state of complete physical, mental, and social well-being — not merely the absence of disease or infirmity. This includes various elements as peace, shelter, education, food, income, a stable eco-system, sustainable resources and social justice.

This sounds a lot like our modern definition of well-being.

As for the term “wellness,” Dr. Bill Hettler and the National Wellness Institute developed the idea of lifestyle dimensions in the 1970s, which had to be achieved in order to have true wellness. These dimensions included physical, emotional, spiritual, intellectual, environmental and social elements. Here and there, others tacked on other components such as relationship, finances or community.

See also: Uncertainty complicates addressing mental health issues

Again, like the term “health” before it, “wellness” was defined in the same very broad holistic way.

What’s odd about this chronology is how we keep re-writing history. For example, compare two quick internet searches: the difference between the terms health and wellness and the difference between the terms wellness and well-being.

Health and wellness are not synonyms. Health refers simply to a physical body being free from diseases, but wellness is an overall balance of your physical, social, spiritual, emotional, intellectual, environmental and occupational well-being.

Likewise, wellness and well-being are not the same thing. Well-being refers to a more holistic whole-of-life experience, whereas wellness refers just to physical health.

It’s like the film “Groundhog Day.” Health, wellness and well-being are all defined pretty much the same way. But every 30 years or so we trash the prior term as too limiting, adopt a new one that looks just like the old one and feel rejuvenated.
How can we make sense of this?

The changes that have occurred over time are actually meaningful. In the 1950s and 1960s, even though the definition of health was expansive and inclusive, the approach was nevertheless constrained. Companies weren’t concerned about how employees felt, just whether they were sick or not. In other words, there was a difference between the theoretical definition of health and its practical application.

This is likely the reason that practitioners wanted to broaden what they saw as an overly narrow approach. Because the definition did not square with what was actually being practiced, it seemed that there needed to be an entirely new framework to rejuvenate the tired and incomplete approach.


10 best gig economy jobs

A new report by CareerCast names these professions as leaders of the independent contracting economy.

So, new wellness wine was put into old bottles, and health became wellness.

The perception was that wellness was a new idea that broke from the past, moving beyond the idea that health represents just the absence of disease. This re-framing worked to popularize its more holistic aspects: the importance of stress, resiliency and better time management.

Today, the same transitional cycle is happening again as the new buzzword, well-being, takes the baton from wellness. Well-being is said to include the social, financial, and environmental elements that wellness lacked. But those who advocate turning from wellness to well-being make the same mistake as their predecessors did 40 years ago.

This kind of linguistic rebirth seems to be necessary to create a renewed sense of purpose and possibility. Yes, it’s self-delusional about its own history, but the new term nevertheless results in fresh elements added into the cultural conversation; that process has helped us to approach the original intent of “health” almost 70 years ago.

In the end, the answer to the original question about “semantics vs. substance” is that it is both, as language pushes the culture to realize the promise of its original nature. The semantics, in this case, help create substance.

Defining “alternative”, “complementary”, “integrative” healthcare

Terminology is important. From the National Center for Complementary and Integrative Health (NIH) site: “…people often use “alternative” and “complementary” interchangeably, but the two terms refer to different concepts: If a non-mainstream practice is used together with conventional medicine, it’s considered “complementary.” If a non-mainstream practice is used in place of conventional medicine, it’s considered “alternative.” True alternative medicine is uncommon. Most people who use non-mainstream approaches use them along with conventional treatments.”

Alternative medicine becomes a lucrative business for U.S. top hospitals

Chinese herbal therapies, acupuncture, homeopathy and reiki are just a few of the offerings that some prestigious medical centers now provide, despite the fact that in many cases there is no evidence the therapies work.

The rise of alternative medicine has created friction within some of these hospitals as many physicians believe it undermines the credibility of the organizations, according to an in-depth investigation of 15 academic research centers by STAT.

The issue came to the forefront earlier this year when the Cleveland Clinic decided to rethink its alternative medicine offerings and how they align with evidence-based practices after the director of the organization’s wellness program went on an anti-vaccine rant in a blog post that sparked an immediate backlash.

The clinic said the wellness center would stop selling some of the products, like homeopathy kits, on its website and focus instead on items that improve diet and lifestyle.

But the STAT investigation noted that the Cleveland Clinic is just one of many that has a hand in the $37-billion-a-year business. Other organizations include Duke University, Johns Hopkins, Yale and the University of California, San Francisco. Some hospitals open spa-like wellness centers, while others, like Duke, refer to them as integrative medicine centers.

Several of the hospitals highlighted in the STAT report declined to talk to the publication about why they have embraced unproven therapies, but critics were quick to point out that patients are being “snookered” and physicians who promote these therapies forfeit claims that they belong to a science-based profession.

“We’ve become witch doctors,” Steven Novella, M.D., a professor of neurology at the Yale School of Medicine and a longtime critic of alternative medicine, told STAT.

Others, however, say that alternative therapies have helped patients and modern medicine doesn’t offer a cure for everyone. Linda Lee, M.D., who runs the Johns Hopkins Integrative Medicine and Digestive Center, said the therapies offered are meant to complement, not supplement, conventional treatment.

But Novella worries that when these unconventional treatments are offered by prestigious institutions, patients will think they are legitimate. The problem only worsens when patients find the treatments being sold online by the institution. Thomas Jefferson University Hospital, for instance, sells homeopathic bee venom to relieve symptoms of arthritis.

Daniel Monti, M.D., who directs the integrative health center at the organization, admits the evidence behind some of these treatments is largely anecdotal but said the hospital only offers the treatment when there are few other options.