39 Deprescribing in palliative care: applying knowledge translation strategies

Mira Maximos, PharmD, MSc, ACPR, BScPhm, BHSc

Sadaf Faisal, BPharm, BCGP, PhD(c)

Introduction

Palliative care aims to reduce the suffering of individuals faced with chronic or life-limiting illness by improving quality of life (QoL) for both patients and their care providers.^1,2 The purpose of palliative care is to manage pain, provide psychological, spiritual, social, and emotional support as well as support family members with the coping and bereavement process.^2,3 Studies have shown that palliative care not only enhances QoL for the patient but also positively influences the course of disease or illness.² Palliative care also encompasses the management of major medical emergencies such as hypercalcemia, spinal cord compression, pain crisis, significant breathing difficulties and bone fractures.^4,5 Hospice is a subdomain of palliative care that is intended to support the dying person in achieving peace, comfort and death with dignity.²

The term “palliative care” was first defined by a Canadian physician, Dr. Balfour Mount in 1975.⁶ Palliative care, at an international stage, began to be recognized for cancer patients in the 1980s with increasing awareness for need in other chronic diseases such as HIV/AIDS, heart failure and neurodegenerative diseases over time.² Thereafter, the World Health Organization (WHO) published guidance on cancer pain therapies in 1986 which was later revised in 1996 to include a guide on opioid availability.⁶ In 2014, the World Health Assembly comprehensive palliative care resolution was created that informed the writings in the Global Atlas of Palliative Care at the End of Life.⁶ Palliative care is still considered an underdeveloped area of practice around the world, particularly outside of North America, Europe and Australia.²

According to the WHO, approximately 40 million people require palliative care every year worldwide with almost 80% of those individuals residing in low to middle-income countries.⁷ However, due to a variety of barriers, there remains an unmet need for palliative care implementation in many parts of the world.² Some of the barriers to the provision of palliative care include: (1) uncertainty or poor experience with palliative care or end of life discussions in the past, (2) lack of recognition of the impact of pain and ineffective symptom management on quality of life, and (3) cultural considerations around the topic of death and dying.^5,8

Knowledge translation, which encompasses knowledge transfer and exchange, refers to the processes and frameworks applied to create a synthesis of evidence and information from research to be translated into a format that is usable for the stakeholder of interest,⁹ be it clinicians, public health or patients and their caregivers. A very commonly applied knowledge translation framework developed by Graham et al. known as the knowledge-to-action framework applies an iterative and dynamic process to move information from research into action.^9,10 Knowledge translation faces a very unique challenge in palliative care environments due to the negative perception of palliation and end-of-life.⁸ Some of the barriers that palliative care researchers often face in the process of knowledge translation in the setting of palliative care are communication gaps, skepticism about the value and strength of evidence for palliative care frameworks, and competing priorities in the health services.⁸ Resources created through knowledge translation can include guidelines, toolkits and education sessions. The process of knowledge translation can help to improve uptake and utilization of palliative care practices around the world.

Polypharmacy, defined as taking five or more medications on a regular basis, whether prescribed or non-prescribed, is common in the palliative setting.^11,12 Polypharmacy has been associated with higher symptom burden and lower quality of life for individuals with advanced illness¹³ with the number of drugs taken being the important predictor of harm.^14,15 Therefore deprescribing can help to optimize medication use, reduce overall medication burden, and avoid drug-related adverse effects and harm. Deprescribing is a systematic approach to identify and discontinue medications where harm outweighs benefit within the context of an individual’s care goals, level of functioning, life expectancy, and values.¹⁵ There have been many approaches to address deprescribing but facets include: (1) obtaining an accurate medication list that includes prescribed and non-prescribed agents, (2) evaluating the risk of drug-induced harm for each agent, (3) determining indication and efficacy of each agent, (4) taking into consideration patient goals, estimated life expectancy and expected lag time for intervention benefit, creating a list of medications to be considered for discontinuation, (5) creating and implementing a deprescribing plan and clear goals for monitoring.^13,15 Further research into the barriers and facilitators to deprescribing in the palliative care setting is needed to support global, local and organizational change, interdisciplinary communication and collaboration with patients and caregivers.¹⁶

Case

CC: “I need help remembering to take my medications, I never know when I’ve taken them and when I’ve forgotten.”

Patient: FR is a 94-year-old male (69 in, 70kg) with advanced Alzheimer’s disease that has been coming to this clinic annually for the past five years. He is accompanied by his 60-year-old son on today’s visit. FR is being seen by your outpatient memory clinic team today after recent discharge from hospital post treatment for E. coli bacteremia and sepsis, with the primary source of sepsis uncertain but urosepsis suspected. FR and his son bring a large shopping bag of medications, natural health products and other over-the-counter products. The medication list that accompanies these prescribed and non-prescribed agents was written 7 years ago by FR’s late wife.

HPI: FR uses a walker as a mobility aid and has a shuffling gait. You note what appears to be a new tremor in his hands bilaterally and increased unsteadiness in his gait. FR is dizzy when moving from sitting to standing and notes that he is dizzy when he gets up from bed in the morning, which has been occurring for the last few months. When asked about his diet, FR notes that he eats food served by the retirement home, at which he resides but is unable to recall examples of meals. FR comes dressed for the Canadian weather, which is currently bitter cold, with a winter coat, scarf, hat, and gloves. FR can recall his name and that he is in a clinic but notes that the year is 1965 and that he is still in Greece, where he was born. He has been residing in Canada for the last 40 years.

FR’s son started to notice a change in how his father was taking medications due to the number of vials, bottles and medicine cups that have been piling up on the kitchen table and on different counters around FR’s residence over the last six months. FR also explained to his son that there were days when he would forget his medications entirely or would be uncertain whether he took them, so would take them again. FR’s son was concerned, particularly after recent illness and hospitalization, so he called you, the memory clinic pharmacist to see if an appointment could be scheduled with the team.

PMH:

• T2DM (diagnosed 20 years ago)
• HTN (diagnosed 15 years ago)
• Dyslipidemia (diagnosed 15 years ago)
• Alzheimer’s disease (diagnosed seven years ago)
• Dysphagia associated with Alzheimer’s disease
• Frequent falls history (three falls in the last year)
• Recurrent colorectal cancer (diagnosed stage IV six weeks ago)
• Insomnia (diagnosed 20 years ago)

Immunizations:

• Tetanus, diphtheria & pertussis booster two years go
• Pneumococcal vaccine four years
• Shingles vaccine three years ago
• Influenza vaccine annually

FH:

• Mother: (deceased 30 years ago; MI)
• Father: (deceased 40 years ago; stage IV lung cancer)
• Siblings: none

SH:

• Social alcohol intake with 1-2 beers per day on weekends

Medications:

Prescription (oral unless noted otherwise):

• Insulin glargine 15 units subcutaneous at night
  • Occasionally checks blood glucose when he feels shaky
  • Home blood glucose readings in 54-72 mg/dL range over the last six months and is not able to help describe how he corrects hypoglycemia
• Atorvastatin 20 mg at night
• Metoprolol tartrate 25mg BID
• Perindopril 4 mg daily
• Amlodipine 5 mg daily
• Donepezil 10 mg daily
• Sitagliptin 50 mg BID
• Pantoprazole 40 mg BID
• Docusate 100 mg TID with food
• Lorazepam 0.5 to 1 mg sublingually at night as needed for sleep
  • This medication was added during a recent admission

OTC:

• Acetaminophen 500 mg QID PRN
• Cetirizine 10 mg daily PRN

Supplements and natural health products:

• Vitalux 1 tablet daily
• CoQ 10 enzyme 1 capsule daily
• Multivitamin 1 tablet daily
• Melatonin 10 mg at night
• Calcium/Magnesium 1 tablet daily
• Vitamin D 2000 IU (2 tabs) daily

Oncology regimen:

• FR’s son explains that his father is on a palliative chemotherapy regimen for his colorectal cancer called FOLFIRI where he goes to an outpatient cancer center every two weeks for IV medications. He sees the oncologist every six months at least and more frequently if there are any concerns.
• FR has a list of his antiemetic regimen, which keep him relatively symptom free for nausea and vomiting and includes:
  • Ondansetron 8 mg BID for three days, start on day of chemotherapy
  • Dexamethasone 8 mg once daily for three days, start on day of chemotherapy (patient educated to take the dexamethasone first thing in the morning with breakfast to avoid affecting sleep)
  • Olanzapine 2.5 mg BID as needed for breakthrough nausea and vomiting (taken very infrequently)

Allergies: NKDA

Vitals:

• BP 114/60 mmHg (seated); 90/65 mmHg (one minute after standing)
• HR 80 bpm and regular (seated); 85 bpm and regular (one minute after standing)
• RR 15/min (seated)

Labs Last checked 72 hours ago:

ROS:

• Integument: N/A
• HEENT: N/A
• Neurologic: See HPI
• Respiratory:
  • Lungs clear to auscultation bilaterally
  • No wheezing, cough, or SOB
• CV:
  • S1 is normal and S2 is normal but faint with a mild diastolic murmur appreciated
  • Peripheral edema, ++ pitting bilaterally
• Gastrointestinal: N/A
• Hepatic/renal: N/A, see labs
• MSK: N/A
• Endocrine: N/A, see labs

Surgical history:

• Cholecystectomy (30 years ago)
• Right knee replacement (20 years ago)

SDH: FR is a retired university professor who speaks English, French and Greek but his fluency of speech has degraded over last year. He previously enjoyed water painting and hiking but has been uninterested in these as of late. He was widowed nine years ago and is not currently in a relationship. He lives in a retirement home and has weekly visits from his only son and daughter-in-law; they have four children (his grandchildren).

Additional context: As the clinic pharmacist, you suggest the following: (1) a home medication review be performed in consultation with FR’s primary care provider, (2) removal of all old medications from the residence, and (3) discussion around starting a blister pack to reduce the number of loose vials and other containers around the residence.

Case Questions

1. Provide a patient-centered explanation of palliative care to FR and his son.

2. Why is it important to address polypharmacy in the palliative care setting?

3. How is deprescribing defined?

4. FR is interested in the involvement of a palliative focused plan to his care while continuing to receive chemotherapy and treatment for Alzheimer’s Disease. Provide a framework for deprescribing FR’s medication list with patient goals in mind.

5. Discuss some of the barriers and facilitators to knowledge translation in the palliative care setting.

6. List the three most important medications in FR’s regimen to consider for deprescribing and provide the reasoning for each of your choices. Based on FR’s goals, he wishes to discontinue medications that have risk of causing harm and side effects.

7. List some of the other agents that you would consider discontinuing in the future with appropriate references to support deprescribing.

Author Commentary

Studies have shown that palliative care can enhance quality of life for the patient and may also positively influence the course of disease or illness.² For example, a study of patients with metastatic non-small-cell lung cancer found that early palliative care was associated with better quality of life and mood, such as lower rates of depressive symptoms, as compared to patients who received standard care alone.¹⁷ Authors noted that 33% of the palliative patients in comparison to 54% received aggressive end of life therapies and mean survival was longer amongst patients who received early palliative care.¹⁷ The ultimate goal is to integrate palliative care into mainstream healthcare systems around the world in order to ensure that patients who are in need of palliative care receive it. As healthcare providers, pharmacists are in a unique position to optimize medication regimens and reduce the medication burden for patients.²

Patient Approaches and Opportunities

Pharmacists can improve patient quality of life and caregiver burden by deprescribing unnecessary medications, ultimately lessening drug-drug interactions and reducing drug-related adverse effects. A patient-centered approach to deprescribing should be applied and should include the patient and involved family and caregivers.¹³ In order to integrate evidence-based palliative care practices into clinical settings, utilize effective communication and engagement strategies with key stakeholders during the research process to overcome barriers and improve potential buy-in.⁸