Why are treatment medications discontinued when a patient transitions to hospice care?

Why Treatment Medications Are Discontinued When Patients Transition to Hospice

When a patient transitions to hospice care, treatment medications are discontinued because the focus shifts from prolonging life toward maintaining quality of life, with emphasis on symptom management and comfort measures rather than disease-modifying treatments.

Shift in Treatment Goals

• The transition to hospice represents a fundamental change in care goals from life-prolonging treatments to comfort-focused care that prioritizes quality of life 1, 2
• For patients with weeks to days to live, anticancer therapy and other disease-modifying treatments should generally be discontinued in favor of intensive palliative care focusing on symptom control and preparation for the dying process 1
• The National Comprehensive Cancer Network recommends that patients with months to weeks to live should consider potential discontinuation of anticancer treatment and be offered best supportive care 1, 2

Benefits of Medication Discontinuation in Hospice

• Discontinuing medications with questionable benefit at the end of life reduces pill burden and treatment-related adverse effects 3, 4
• Stopping medications that no longer align with goals of care helps avoid unnecessary side effects that may diminish quality of life 5, 3
• Medication discontinuation should be reframed as "fighting for better quality of life" rather than "giving up," as recommended by the National Comprehensive Cancer Network 1, 2

Types of Medications Commonly Discontinued

• Medications typically discontinued include:
  • Statins and antihyperlipidemics (10% of deprescribing recommendations) 3, 6
  • Antihypertensives (7% of deprescribing recommendations) 3, 6
  • Anticoagulants and antiplatelets (20% combined) 3, 5
  • Antidiabetic medications (13% of deprescribing recommendations) 3, 4
  • Vitamins and supplements (20% of deprescribing recommendations) 3
  • Proton pump inhibitors/H2 blockers (7% of deprescribing recommendations) 3, 6
  • Dementia medications (1% of deprescribing recommendations) 3, 6

Decision-Making Framework for Medication Discontinuation

• Factors to consider when systematically reviewing medications include:
  • Goals of care and patient preferences 5, 1
  • Remaining life expectancy 5, 1
  • Time until benefit versus time remaining 5, 4
  • Number needed to treat versus number needed to harm 5
  • Potential for adverse drug reactions 5, 4
  • Pill burden and treatment burden 3, 4

Special Considerations for Medication Discontinuation

• Some medications require careful tapering rather than abrupt discontinuation to avoid withdrawal syndromes 7, 1
• Certain drug classes, especially those that act on the cardiovascular or central nervous system, need to be discontinued cautiously to avoid adverse drug withdrawal events 1, 7
• Opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate management of dyspnea and pain 1

Medications Typically Continued in Hospice

• Medications for symptom management are maintained or initiated, including:
  • Opioids for pain and dyspnea management 1
  • Benzodiazepines for anxiety and sedation 1
  • Anticholinergics for secretion management 1, 8
  • Medications that directly address comfort and quality of life 1

Common Pitfalls in Medication Management During Hospice Transition

• Burdensome healthcare transitions are associated with a 33% increase in the risk of receiving at least one limited benefit medication after hospice admission 6
• Antidepressant use is often disrupted during patients' final days without proper tapering, which may lead to discontinuation syndrome 7
• Some clinicians may fear liability regarding underuse of therapies and may continue medications even when the benefit is unclear in the context of the patient's overall health status 1
• Failure to recognize that withholding or withdrawing ineffective, futile, burdensome, and unnecessary life-prolonging treatments is ethically appropriate and does not constitute euthanasia or physician-assisted suicide 1

By aligning medication management with the patient's goals of care and focusing on symptom control rather than disease modification, the hospice approach ensures that patients receive appropriate care that maximizes comfort and quality of life during their final days.