From the Guidelines
In a hospice patient with metastatic colon cancer, diabetes, hypertension, hyperlipidemia, and obesity, I strongly recommend discontinuing atorvastatin (Lipitor), hydrochlorothiazide, and losartan, as these medications are primarily for long-term prevention and may no longer provide meaningful benefit in end-of-life care, as supported by the most recent guidelines 1. The goal of care in hospice patients shifts from prevention of long-term complications to comfort and symptom management.
- Medications that can be discontinued include:
- Atorvastatin (Lipitor) for hyperlipidemia, as the intensity of lipid management can be relaxed in palliative care, and withdrawal of lipid-lowering therapy may be appropriate 1.
- Hydrochlorothiazide for hypertension, as strict blood pressure control is not necessary in palliative care, and the focus should be on preventing distressing symptoms and preserving quality of life 1.
- Losartan for hypertension, as it is not essential for symptom management in end-of-life care.
- For diabetes management, the insulin regimen should be simplified, potentially transitioning from the basal-bolus approach (glargine and lispro) to a simplified regimen using only long-acting insulin with less frequent monitoring, focusing on preventing symptomatic hyperglycemia rather than tight control, as recommended by the American Diabetes Association 1.
- Blood glucose targets can be relaxed to 200-300 mg/dL to avoid hypoglycemia while preventing symptoms of severe hyperglycemia, aligning with the goals of palliative care 1. This approach reduces pill burden, minimizes side effects, and focuses treatment on interventions that provide immediate symptom relief and comfort in the limited life expectancy of hospice care, as emphasized by the American Heart Association 1.
From the Research
Medication Management in Hospice Patients
In a hospice patient with metastatic colon cancer, diabetes, hypertension, hyperlipidemia, and obesity, the goal of medication management is to prioritize symptom control and quality of life. The patient's current medications include aspirin, Lipitor (atorvastatin), hydrochlorothiazide, insulin glargine, insulin Lispro, and losartan.
Medications to Consider Discontinuing
- Atorvastatin: According to 2, statins have a proven benefit in terms of mortality and/or morbidity in patients with hypercholesterolaemia. However, in a hospice patient, the focus shifts to symptom control, and the benefit of continuing atorvastatin may be limited.
- Hydrochlorothiazide: This medication is used to treat hypertension, but its continuation in a hospice patient may not be necessary, especially if the patient's blood pressure is not a concern at the end of life.
- Insulin glargine and insulin Lispro: These medications are used to manage diabetes, and their continuation is likely necessary to control the patient's blood sugar levels. However, the dosages may need to be adjusted based on the patient's changing condition.
- Losartan: This medication is used to treat hypertension, and its continuation in a hospice patient may not be necessary, especially if the patient's blood pressure is not a concern at the end of life.
General Principles of Medication Management in Hospice Patients
- The goal of medication management is to prioritize symptom control and quality of life 3.
- Medications that are not essential for symptom control or quality of life can be discontinued 4.
- The use of multiple medications (polypharmacy) can increase the risk of adverse effects, and a more streamlined approach to medication management may be beneficial 3.