Top Tips: Managing Medication in the Last Years, Months and Days of Life

FINAL DRAFT: 28.01.14

Top Tips: Managing Medication in the Last Years, Months and Days of Life

Local Consensus Guidance for Health Professionals in North East London

October 2013

Commissioned by Tower Hamlets Clinical Commissioning Group

St Joseph’s Hospice were commissioned to produce this guidance by the Tower Hamlets Clinical Commissioning Group

Contributors

Many thanks go to all those who have contributed to the guidance as either authors or reviewers, listed below in alphabetical order:

Jane ButlerNurse Consultant for Heart Failure

Dr Tim Crocker-BuqueQueen Mary’s University of London (QMUL)

Dr Kate CrosslandStaff Grade, St Joseph’s Hospice

Jaryn GoClinical Nurse Specialist Renal Supportive & Palliative Care Service Barts Health

Dr Ellie HitchmanStaff Grade, St Joseph’s Hospice

Dr Isabel HodkinsonPrincipal Clinical Lead, Tower Hamlets CCG

Matthew HodsonCOPD Nurse Consultant, Homerton University Hospital NHS Foundation Trust

Diane Laverty, Nurse Consultant, St Joseph’s Hospice

Dr Anna Eleri LivingstoneGP and Clinical Lead Medicines THCCG

Dr Jonathon Martin. Consultant in Palliative Medicine, St Joseph’s Hospice

Professor Allyson PollockQMUL

Dr Aleksandar RadunovicConsultant Neurologist, Barts MND Centre, Barts Health NHS Trus

Dr Liliana RisiGP Clinical Lead Last Years of Life, NHS Tower Hamlets Clinical Commissioning Group

Dr Hattie RoebuckConsultant in Palliative Medicine, St Joseph’s Hospice

Dr Clare ThormodClinical Lead for Dementia, Frail Elderly and Last Years, Months and Days of Life, Newham CCG

Dr Abigail WrightConsultant in Palliative Medicine

Prof Magdi YaqoobProfessor in Renal Medicine, Barts Health

Editor

Dr Anjali Mullick Clinical Lead, St Joseph’s Hospice

CONTENTS:

Introduction:Managing Medication in the Last Years, 3

Months and Days of Life

Background4-7

Top Tips:

Frail Elderly 8-9

Dementia10-12

Diabetes13-15

Chronic obstructive pulmonary disease16-21

Heart Failure22-23

Chronic Kidney Disease24-28

Liver Disease29-30

Cancer31-33

Progressive longterm neurological conditions34-39

The last days of life40-42

Appendices

Useful resources43

Managing Medication in the Last Years, Months and Days of Life:

Local Consensus Guidance for Professionals

Can this guidance help you and your patients?

This guidance may be helpful if:

You are a health professional in the acute or primary care sector in North East London caring for a patient suspected to be in the last years, months or days of their life due to progressive incurable illness.
You are directly involved in prescribing for that patient or giving advice about prescribing.
The patient’s clinical condition is changing and you are unsure about the current benefit, burdens and risks of their medication regime.
The patient has queries or concerns about their medication regime, including issues around side effects or medication burden.

Aim of Guidance

To provide a practical approach to rationalising medications in the last years, months or days of life in order to identify medications that may provide clinical benefit and avoid unnecessary medicines that do not or where the balance of risk outweighs benefit.

The expectation is that this guidance is implemented within a context of working in partnership with the patient and their family, with clear and open communication with the patient and their family and across the multidisciplinary team.

We would encourage the use of Coordinate my Care to communicate relevant decisions about medications in the section on ‘Ceiling of treatment’.

What this Guidance Contains

Background of the importance of appropriate prescribing in this patient group.
Factors to consider when prescribing for those in the last year of life
Top Tips for several diseases or situation specific categories written by local clinicians, including:

Frail elderly
Dementia
Diabetes
Respiratory disease
Heart Failure
Chronic kidney disease
Liver disease
Progressive long term neurological conditions
Cancer
The last days of life

Signposting to relevant local and national guidance where available

Background

Case Study

The following case study gives an example where decision making around medications may need to take place for a lady likely to be in her last year of life

90 year old Jane lives with her 68 year old daughter. Jane’s best days are when she is not breathless from her COPD, when her diabetes is well controlled and when she is not agitated from her dementia and depression (Her other diagnoses include Hypertension, raised cholesterol and she is high risk for fracture of the femur on Dexa Scan)
Jane has had multiple episodes in hospital in the year before she dies but no clear medication review is done or documentation sent to the GP
In the last year of her life, eight different GPs were involved in her care – but her records show no documentation of her mental state or ability to make an advanced care plan (neither in the community or nor during her stay in hospital)
In the last year of life she is on 14 different medicines listed below

Metformin 500mg bd

Glipizide 5mg od

Salbutamol 2 puffs prn

Tiotropium [Spiriva] 2 puffs daily

Alendronate 70mg weekly

Furosemide 20mg od

Aspirin 75mg od

Citalopram 20mg od

Simvastatin 40mg on

Amlodipine 5mg od

Paracetamol 1g qid

Quetiapine 25mg am / nocte and 12.5mg pm

Trazadone 25mg am, 30mg nocte

Omeprazole 20mg od

How might you approach a medication review for this lady?

What further information might help you with this?

There is a wide body of evidence to show that taking multiple medications (polypharmacy) is common in older people and that this can cause adverse drug events and adverse health outcomes 1,2,3. Although not all people in the last years, months and days of life are elderly, a significant number of them are. Whilst there is limited evidence for younger patients with a short life expectancy, it is possible that similar risk of adverse drug events and adverse health outcomes also applies. In addition where there is short life expectancy the balance between quality of life and the burden of treatment may well shift.

This guidance aims to enable healthcare professionals to identify appropriate medications that are likely to give patients genuine benefit in terms of quality or length of life, and avoiding the use of futile medications or those which are causing more harm than good.

Individualised care is paramount. This guidance does not aim to give ‘dos and don’ts’, but instead provides professionals with a set of principles that can be applied in a wide variety of circumstances. Shared decision making with patients is also essential, taking into account the patient’s goals, beliefs and values. Treatment targets in the palliative care population can include life prolongation, prevention of morbidity and mortality, maintenance of current state or function and treatment of acute illness4

PLEASE NOTE: This guidance is designed to cover management of medication only. Whilst some sections refer to potential non pharmacological strategies for symptom management, practitioners will need to consider these alongside the medication guidance outlined contained here.

Why might you need to rationalise the medication of a patient in the last years, months or days of life?

Patients in the last years, months or days of life may have no opportunity to benefit from medications that require several years to achieve a clinical benefit (e.g. statins to lower cholesterol). They may have time to benefit from medications aimed at symptom relief such as analgesics, even if close to death. 4,5

For people with comorbidities, both the comorbidities and the life limiting illness change over time and therefore medication needs regular review.6 For example, progressive illness can lead to changes in metabolism that may have an impact on drug metabolism 7

Patients can be vulnerable to the ‘prescribing cascade’, where an adverse drug reaction is misinterpreted as a new medical condition and a new drug started, further increasing the risk of adverse drug effects. The risk of a serious adverse drug interaction is greater than 80% when more than seven drugs are taken 4,6,8

Harm caused by inappropriate prescribing can lead to significant cost and resource implications for the NHS as a whole as a result of unnecessary hospital admission. According to the National Prescribing Centre (NPC), in 2001, medication problems were implicated in 5-17% of hospital admissions, with similar proportions of older people experiencing adverse drug reactions. The estimated cost of medication errors at that time equated to £500 million a year.1

Potential benefits for you and your patients:

In general terms, according to the National Prescribing Centre (NPC)9, medication review can have the following benefits:

Improving the current and future management of the patient’s medical condition
Opportunity to develop a shared understanding between the patient and practitioner about medicines and their role in the patient’s management
Improved health outcomes through optimal medicines use
Reduction in adverse events related to medicines
Opportunity to empower patient and carers to be actively involved in their care and treatment through the clarification of the goals of care
Reduction in unwanted or unused medicines

Challenges in reviewing medication

Clinical care frequently involves balancing the recommendations of multiple single disease guidelines in people who have different conditions 10which can apply to patients with palliative care needs.
Palliative care patients are often excluded from clinical trials, making applying evidence difficult to this population.
Predicting rate of deterioration and prognosis may be difficult, particularly when deciding whether to stop a medication with a long term benefit.

Undertaking a medication review

Given the potential benefits of rationalising medications for patients in the last years, months or days of life, it is helpful to undertake a medication review

Who should do it?

It can be undertaken by any prescriber involved in the patient’s care. Communication and coordination of care is essential and relevant professionals should be made aware if significant changes to medication are made.

Any healthcare professional can suggest a medication review.

Approach to review

Patients should be central to the process. Goals of care6,7, both generally and with respect to medications should be transparent and negotiated with consideration to personal, spiritual, religious, and cultural beliefs whilst maintaining autonomy, self-worth, and social participation11,12 and communicated well across provider boundaries. With respect to goal setting, shared agenda setting and goal follow up are the basis of ‘coproduction’13.

When should it be done?

Triggers for review:

- Change in terminal or comorbid condition 5

- Suspected or actual adverse drug reaction

- Burden now outweighing the benefit

- Patient or carer initiating review

- Routine review

How should it be done?

initiate discussion with patient and families- may take place as one off or over time7
use the medication appropriateness index or similar tool to guide the review 4,5,14,15
when stopping medications taper gradually and monitor for withdrawal reactions 11
add in drugs that may be necessary e.g. for symptom benefit

frequent review and monitoring, 7,14 of impact of changes made and tailored to a patients changing condition and treatment goals

The medication appropriateness index 10

This is a 10 question tool that can identify potentially inappropriate elements of prescribing4,15

Is there an indication for the drug?
Is the medication effective for the condition?
Is the dosage correct?
Are the directions correct?
Are the directions practical?
Are there clinically significant drug-drug interactions?
Are there clinically significant drug-disease/condition interactions?
Is there unnecessary duplication with other drugs?
Is the duration of therapy acceptable?
Is the drug the least expensive alternative compared with others of equal usefulness?

The NHS Scotland Polypharmacy Guide 20125 has a similar framework with the following additions:

Is the medicine preventing rapid symptomatic deterioration?
Is the medicine fulfilling an essential replacement function?
Do you have the informed agreement of the patient/carer/welfare proxy?

 References

National Prescribing Centre and National Primary Care Research and Development Centre Modernising Medicines Management- A Guide to Achieving Benefits for Patients, Professionals and the NHS (Book 1) 2002 cited on 23.09.12 available on

Audit Commission A Spoonful of Sugar: Medicines Management in NHS Hospitals 2001 cited on 23.09.13 available from http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/nrspoonfulsugar.pdf

Department of Health Medicines and Older People National Service Framework: Implementing Medicines-Related Aspects of the NSF for Older People 2001 cited on 23.09.13 available from http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4067247.pdf

Holmes H, Hayley DC, Alexander GC, Sachs GA Reconsidering Medication Appropriateness for Patients Late in Life Arch Intern Med 2006;166:605-609

NHS Scotland Polypharmacy Guidance October 2012 cited on 23.09.13 available from

Stevenson J et al Managing Comorbidities in Patients at the End of Life BMJ 2004;329:909-12

O’Brien P Withdrawing Medications: Managing Medical Comorbidities Near the End of Life Can Fam Physician 57(3):304-307

Rochon PA Gurwitz JH Optimising Drug Treatment for Elderly People: The Prescribing Cascade BMJ 1997;315:1096

National Prescribing Centre A Guide to Medication Review 2008 cited on 23.09.13 available from

Barnett K et al Epidemiology of Multimorbidity and Implications for Healthcare, Research, and Medical Education: a cross sectional study Lancet 2012 DOI:10.1016.S0140-6736(12)60240-2

Rehabilitation in end of life management. Curr Opin Support Palliat Care 2010 www.ncbi.nlm.nih.gov/pubmed/20479642

Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice. J Clin Epidemiol. 2012. http://www.ncbi.nlm.nih.gov/pubmed/22910536

Coproduction of health and wellbeing outcomes: the new paradigm for effective health and social care. March 2013

Steinman MA Hanlon JT Managing Medications in Clinically Complex Elders-There’s Got to be a Happy Medium JAMA 2010 304(14) 1592-1601

Hanlon, JT, Schmader KE, Samsa GP et al A Method for Assessing Drug Therapy appropriateness J Clin Epidemiol 1992;45:1045-1051

Top Tips: Frail Elderly Patients

 What are the common or significant health and symptom burdens for frail elderly patients with in the last years, months and days of life?

In this guidance the term ‘frail elderly’ is used to mean older people with complex needs arising from multiple comorbidities and decline in physical function due to the aging process

memory loss
reduced mobility with risk of falls, sometimes becoming bed-bound
weight loss
reduced dietary intake/progressive difficulty with chewing/ swallowing risking aspiration or choking
incontinence
pressure sores
infections; chest, bladder

 Types of medications commonly used in the frail elderly

Medication Group / Benefits / Risks/Burdens
Anticoagulants:
Aspirin/clopidogrel/warfarin / Minimise risk of vascular events / Bleeding/gastric irritation
Monitoring INR if on warfarin
Anti-hypertensives e.g. ACEI / Minimise risk of vascular events. / Symptomatic hypotension, electrolyte disturbance requiring monitoring – may need to consider dose reduction
Statins / Minimise risk of vascular events long-term / Tablet burden
Hypoglycaemic agents / Avoid symptomatic hyperglycaemia / Hypoglycaemia particularly with reduced oral intake
Bisphosphonates and Calcium/ Vat D / Reduce risk of fractures / Gastric side effects, hypocalcaemia and tablet burden
Anti-depressant e.g. SSRI, TCA / Improve mood and quality of life / Interactions, (postural instability and falls with TCAs)
Heart failure medication (see section 8 of this guidance for more details) / Control of heart failure symptoms / Symptomatic hypotension, electrolyte disturbance requiring monitoring – may need to consider dose reduction

 Medications that may need stopping as overall condition deteriorates

Anti-coagulants – monitoring levels burdensome and invasive, increased risk of bleeding

Anti-hypertensives – as weight reduces, anti-hypertensives may no longer be necessary

Lipid lowering agents – tablet burden and aimed at modifying long term risk of further vascular events

Hypo-glycaemic agents – aim should be keeping patient asymptomatic rather than trying to prevent microvascular complications. Poor appetite and limited oral intake risks hypoglycaemia. Avoid oral sulphonylureas if food intake is poor variable. (For further details on diabetes management see section 9 of this guidance)

Diuretics – renal impairment common in frail, older patients with reduced oral intake – risk of toxicity/increased toxicity from other medication

Bisphosphonates – need to balance long term fracture prevention with risk of GI side effects

Anti-depressants – need to balance beneficial effect on mood with side effects such as hypotension

Heart failure medication – consider stopping those which are solely for long term survival benefit , e.g. ACE inhibitors but continuing those which offer symptomatic benefit e.g. diuretics (see section 8)

 Medications that may need continuing as overall condition deteriorates

Main consideration will be route of administration if oral route inconsistent-consider other routes such as transdermal or rectal

Analgesics

Laxatives/bowel intervention

Memantine if psycho-behavioural symptoms

 Medications that may need introducing as overall condition deteriorates

Main consideration will be route of administration if oral route inconsistent-consider other routes such as transdermal or rectal

Pain / Buprenorphine patches, PR paracetamol/ diclofenac, if opioid naïve and opioids required for acute pain – start low and go slow e.g. diamorphine 1.25mg subcut PRN.
Breathlessness, anxiety or agitation / Lorazepam 0.5mg sublingual PRN (max 4mg in 24 hours), midazolam 1.25mg subcut PRN
Respiratory secretions / Glycopyrronium 0.2-0.4mg subcut PRN, max 2.4mg in 24 hours
Nausea and vomiting / (depends on aetiology) metoclopramide 10mg subcut PRN (avoid in Parkinsonism/ Parkinson’s disease/ concomitant bowel obstruction), Cyclizine 25-50mg subcut PRN, Domperidone suppositories 10mg PRN.

 Key references

Preventative medication use among persons with limited life expectancy. Maddison et al. Progress in Palliative Care vol 19 no 1, 2011

 Useful resources

Top Tips: Patients with Dementia

 What are the common or significant health and symptom burdens for patients with dementia in the last years, months and days of life?

memory loss
increasing problems understanding what is being said to them and what is going on around them
progressive loss of speech
reduced mobility with risk of falls, sometimes becoming bed-bound
weight loss
poor initiation of eating/drinking requiring prompting or progressive difficulty with chewing/ swallowing risking aspiration or choking
incontinence
psycho-behavioural problems; agitation, hallucinations
pressure sores
infections; chest, bladder
Seizures

 Types of medications commonly used in dementia disease