Why is treatment withheld during hospitalization?

Why Treatments May Be Withheld During Hospitalization

Treatments may be withheld during hospitalization due to hemodynamic instability, contraindications, risk of adverse effects, or when the treatment is no longer providing benefit to the patient's condition. 1

Guideline-Based Reasons for Withholding Treatment

Heart Failure Medications

For patients hospitalized with heart failure, certain medications may be temporarily withheld for specific reasons:

• Beta-blockers: Should be considered for withholding or reduction only in patients with:

  • Recent initiation or increase in beta-blocker therapy
  • Marked volume overload
  • Marginal/low cardiac output
  • Hemodynamic instability 1

• ACE inhibitors, ARBs, and aldosterone antagonists: Should be considered for reduction or temporary discontinuation in:

  • Patients with significant worsening of renal function
  • Until renal function improves 1

Diabetes Medications

Diabetes medications may be withheld during hospitalization for several reasons:

• During acute illness: Patients are at higher risk for administration or dosing errors that can result in hypoglycemia, falls, and fractures 1

• After hospitalization for acute illness: If the patient experienced:

  • Weight loss
  • Anorexia
  • Short-term cognitive decline
  • Loss of physical functioning 1

• When treatment regimen increased in complexity during hospitalization: It is often reasonable to reinstate the pre-hospitalization medication regimen 1

Other Medications

• Thiopurine monotherapy: Not recommended for inducing remission in Crohn's disease patients requiring hospitalization 1

• Any medication without clear benefits: Should be considered for discontinuation, especially in complex/poor health patients 1

Clinical Decision Framework for Withholding Treatment

Step 1: Assess Patient Stability and Risk

• Evaluate for hemodynamic instability (hypotension, tachycardia)
• Check for signs of organ hypoperfusion
• Review renal and hepatic function
• Assess for risk of adverse drug reactions

Step 2: Consider Medication-Specific Factors

• Review the risk-benefit profile of each medication
• Evaluate potential drug-drug interactions
• Consider the pharmacokinetic changes during acute illness

Step 3: Determine Appropriateness of Continuing Treatment

Withhold treatment when:

1. The medication may worsen the current clinical condition
2. The patient is unable to safely receive the medication
3. The medication is no longer providing benefit
4. The risk of adverse effects outweighs potential benefits

Special Considerations

Ethical Aspects of Withholding Treatment

• A medical treatment that does not provide any benefit or has become disproportionate can be withdrawn or withheld 1
• Limitation of treatment may involve progressively withdrawing it or reducing the dose to limit side effects 1

Avoiding Unnecessary Hospitalizations

• Up to 50% of emergency department patients with heart failure could potentially be safely discharged after a brief observation period 2
• Unnecessary hospitalizations expose patients to risks including medication errors and hospital-acquired infections 3, 4

Common Pitfalls to Avoid

1. Continuing all home medications by default: Each medication should be individually assessed for appropriateness during hospitalization

2. Abrupt discontinuation of certain medications: Some medications (e.g., beta-blockers) may require gradual tapering rather than sudden discontinuation

3. Failure to restart withheld medications: Create a clear plan for when and how to restart medications that were temporarily withheld

4. Inadequate communication: Ensure clear documentation of why medications were withheld and under what conditions they should be restarted

5. Unnecessary antimicrobial therapy: Avoid prolonged courses, treatment of non-infectious syndromes, or treatment of colonizing organisms 5

By following these guidelines and considering the individual patient's clinical status, clinicians can make appropriate decisions about when to withhold treatments during hospitalization while optimizing patient outcomes.