Deprescribing Medications at the End of Life: Experts Discuss Challenges and Strategies

The GeriPal Podcast recently hosted a compelling discussion featuring leading experts in geriatrics and palliative care, delving into the critical and often complex topic of deprescribing medications at the end of life. The conversation, moderated by Eric Widera and Alex Smith, brought together Dr. Jen Tjia, a geriatrician and palliative care researcher currently on a Fulbright scholarship in the Netherlands; Dr. Simon Mooijaart, Chair of Geriatrics and Gerontology at Leiden University Medical Center; and Dr. JJ Furuno, an epidemiologist specializing in hospice and palliative care research. The experts highlighted the significant challenges and the urgent need for better strategies to manage medication burdens in patients nearing the end of life, aiming to improve quality of life and align care with patient goals.

The Imperative of End-of-Life Deprescribing

The discussion was initiated by the fundamental question: "Why focus on deprescribing at the end of life?" Dr. Jen Tjia shared a poignant personal experience that sparked her interest: caring for a terminally ill patient whose family was overwhelmed by the complexity of managing numerous medications. This experience revealed the unintended consequences of polypharmacy, where the burden of administration and the anxiety surrounding missed doses could detract from the patient’s and family’s quality of life. "We have to do something about this and make it simple," she emphasized, noting that this was long before the widespread adoption of the "less is more" philosophy in geriatric care.

Dr. Simon Mooijaart echoed this sentiment, drawing from his clinical practice where he observed the persistent challenge of stopping medications compared to initiating them. He expressed concern over patients dying while still taking a multitude of medications, highlighting it as both an "intriguing puzzle" and a barrier to delivering truly good end-of-life care.

Dr. JJ Furuno, an epidemiologist, approached the topic from a research perspective, initially focusing on antimicrobial stewardship in nursing homes. This led him to investigate antibiotic use in hospice and palliative care settings, revealing a significant percentage of patients still receiving antibiotics in their final week of life, a finding published in the Journal of Palliative Medicine. This research underscored the need to scrutinize medication practices across different care settings, especially when evidence supporting their continued use is lacking.

Identifying Medications for Deprescribing: The "Top Three"

The conversation then shifted to identifying specific classes of medications that are frequently considered for deprescribing at the end of life.

Statins: These cholesterol-lowering drugs emerged as a clear candidate for deprescribing. Dr. Tjia noted that statins are "definitely up there" on the list. The rationale is that the long-term benefits of statins, such as cardiovascular event prevention, typically manifest over years, a timeframe often inconsistent with the prognosis of patients receiving palliative or hospice care. A significant randomized controlled trial led by Dr. Gene Kutner demonstrated that deprescribing statins in hospice-eligible patients did not negatively impact their quality of life and potentially improved it, suggesting that their continued use may not be beneficial.

Antithrombotic Medications: This category, including anticoagulants and antiplatelet agents, was identified as more complex and controversial. Dr. Tjia mentioned that these are "hard" to stop, especially given the high prevalence of atrial fibrillation in end-of-life patients. Dr. Furuno’s research also highlights this area, aligning with work by the Serenity Group in Europe. The challenge lies in balancing the risk of stroke with the risk of bleeding, both of which can significantly impact quality of life. Dr. Simon Mooijaart elaborated on the difficulty of discontinuing these medications, as cardiologists often emphasize their necessity for preventing life-threatening events, creating a formidable barrier for patients and families.

Thyroid Medications: Dr. Mooijaart highlighted thyroid medications, particularly for subclinical hypothyroidism, as another area of concern. He noted that many patients have been on these medications for years without clear benefit, especially at lower doses. The rationale for deprescribing is based on studies suggesting limited efficacy in certain populations, particularly when the primary indication might be outdated or less relevant in the context of end-of-life care.

Dementia Medications: These medications, primarily acetylcholinesterase inhibitors and memantine, were also discussed. Dr. Tjia and Dr. Widera agreed that their efficacy in end-stage dementia is questionable. Dr. Widera stated there is "zero evidence that they benefit" in end-of-life dementia, and while there might be a theoretical benefit in moderate dementia, the risks, including nausea and decreased appetite, often outweigh potential advantages. Dr. Tjia wryly commented that while some might argue geriatricians don’t know how to prescribe them, the reality is they "don’t work anyways."

Antibiotics: Dr. Furuno, with his background in infectious disease epidemiology, emphasized the overuse of antibiotics in end-of-life care. He pointed out that many indications, such as asymptomatic bacteriuria or even some cases of pneumonia, may not warrant antibiotic treatment in this population. The evidence supporting their benefit in improving comfort or quality of life is often lacking, and in some cases, antibiotics can prolong life in ways that may not align with palliative goals, potentially even leading to complications like C. difficile infections.

Other Medications: Other "easy calls" for deprescribing included medications for tight glycemic control (where the lag time to benefit is years) and some antihypertensives. Medications for benign prostatic hyperplasia (BPH), like finasteride, were also mentioned due to their long time to benefit. Vitamins and supplements, such as calcium and Vitamin D, were also flagged as often unnecessary in the absence of specific conditions like osteoporosis.

Challenges in End-of-Life Research and Practice

Conducting research on deprescribing at the end of life presents unique hurdles. Dr. Mooijaart outlined several key difficulties:

• Regulatory Hurdles: Clinical trials are inherently complex due to regulatory requirements.
• Defining Endpoints: Measuring meaningful outcomes like quality of life in patients who are imminently dying is challenging. Traditional endpoints like mortality may not capture the nuances of end-of-life care.
• Patient Population Size: The specific population for end-of-life research can be small, necessitating multi-center or multi-national collaborations.
• Identifying the "End of Life": Accurately predicting and identifying patients within a specific timeframe of death for research purposes is difficult, impacting study design and recruitment.

The DONTAL trial, discussed by Dr. Mooijaart, highlighted a concerning finding where tapering antihypertensive medications in frail nursing home residents with dementia led to increased mortality, falls, and heart failure, underscoring the need for careful consideration and individualized approaches.

Strategies for Navigating Complex Decisions

Given the complexity, particularly with medications like anticoagulants, the experts discussed the importance of structured approaches to facilitate shared decision-making.

Frameworks for Conversation: Dr. Jen Tjia introduced two valuable frameworks:

• FRAME: This acronym stands for Fortifying Trust, Reviewing willingness/barriers, Aligning recommendations, Managing cognitive dissonance, and Empowering continuation of the conversation. It emphasizes building trust with patients and families when discussing medication changes, especially when long-held beliefs about medication necessity are challenged.
• Goal-Concordant Prescribing (GCP): Developed by her group with Ariadne Labs, GCP focuses on aligning medication decisions with the patient’s and family’s goals. It involves reviewing the patient’s current medications, understanding their goals for life and for their medications, and then aligning prescribing practices accordingly. The emphasis is on a positive, goal-oriented approach, rather than simply "deprescribing."

Addressing Family Concerns and Cognitive Dissonance: Dr. Simon Mooijaart highlighted that patients and families often have different perspectives. Clinicians may focus on side effects (like bleeding risk with anticoagulants), while patients and families may prioritize preventing adverse events like strokes. This discordance makes conversations challenging. He also noted the "cognitive dissonance" that can arise when patients have taken medications for years, and suddenly being told to stop them can feel like an acknowledgment of imminent death. He advocates for a step-down approach, where radical changes are not made all at once, especially when transitioning to hospice.

The Role of the Clinician: Dr. Mooijaart also pointed out the challenge of "ownership" in deprescribing decisions. Cardiologists may defer to palliative care specialists, who may defer back to primary care physicians or hospital specialists. Targeting specific patient groups, like cancer patients under oncologists, can help establish clear lines of responsibility.

The Anticoagulant Dilemma: A Case Study

The discussion on anticoagulants, particularly DOACs (direct oral anticoagulants), exemplified the complexities. Dr. Eric Widera expressed his personal struggle with this class of drugs, acknowledging the risk of stroke but also the significant risk of bleeding, which can severely impact quality of life at the end of life.

Dr. JJ Furuno cited research indicating that a substantial percentage of patients (up to 80% in one study) continue antithrombotic medications within the last month of life, with an average discontinuation occurring only 14 days before death. He also noted that while patients and clinicians may have differing concerns (patients fearing stroke, clinicians fearing bleeding), the risk of both is elevated in this population. Furthermore, prognostic tools for stroke and bleeding risk, often developed for healthier populations, are less reliable in the end-of-life setting.

Dr. Simon Mooijaart shared findings from the Serenity consortium, where retrospective analysis showed 80% of patients on antithrombotics were still using them one month before death. He emphasized that any bleeding, even a "nuisance bleed" like a nosebleed, can negatively impact quality of life, and this is often overlooked in discussions focused solely on stroke prevention.

Looking Ahead: Future Directions and Conclusion

The conversation concluded with a reflection on the need for continued research, improved communication strategies, and a shift in mindset towards goal-concordant care. The experts agreed that while the term "deprescribing" can be fraught with negative connotations, frameworks like Goal-Concordant Prescribing offer a more positive and patient-centered approach. The ultimate aim is to ensure that medication regimens truly support the patient’s remaining time, aligning with their values and priorities.

The GeriPal podcast episode underscored the vital importance of critically evaluating all medications at the end of life, moving beyond routine continuation to a thoughtful, individualized approach that prioritizes quality of life and patient-centered goals. The ongoing work of researchers like Tjia, Mooijaart, and Furuno promises to shed more light on these complex issues and provide clinicians with the tools and evidence needed to navigate these sensitive conversations effectively.