What is the recommended approach to lipid management for a patient with multiple medical comorbidities on palliative care with abnormal lipid profiles?

Lipid Management in Palliative Care: Discontinue Lipid-Lowering Therapy

In a patient on palliative care with multiple comorbidities, lipid-lowering therapy should be withdrawn or not initiated, as the focus shifts to comfort, quality of life, and prevention of distressing symptoms rather than long-term cardiovascular risk reduction. 1

Primary Recommendation: Withdraw Statins

• The American Diabetes Association explicitly recommends that when palliative care is needed, the intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate. 1
• A multicenter trial demonstrated that withdrawal of statins among people with diabetes in palliative care improved quality of life. 1
• The 2018 Standards of Care similarly state that withdrawal of lipid-lowering therapy may be appropriate in palliative care settings. 1

Clinical Rationale for Discontinuation

Shift in Treatment Goals

• Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are the primary goals for management at the end of life, not cardiovascular risk reduction. 1
• Strict metabolic control (including lipid management) is not consistent with achieving palliative care goals. 1
• The time horizon for cardiovascular benefit from statins (typically years) far exceeds the life expectancy in palliative care patients. 2

Patient-Specific Lipid Profile Context

• Your patient's LDL-C of 53 mg/dL is already well below any treatment target, making continued therapy unnecessary even in non-palliative settings. 1
• The critically low HDL-C of 18 mg/dL and total cholesterol of 93 mg/dL likely reflect advanced illness and poor nutritional status rather than a lipid disorder requiring treatment. 3
• Low LDL-C levels (<130 mg/dL) in terminal cancer patients are associated with shorter survival times (hazard ratio 4.201), suggesting these values reflect disease severity rather than cardiovascular protection. 3

Avoiding Common Pitfalls

Polypharmacy Burden

• Palliative care patients average 7.2 regular medications, placing them at high risk for drug-drug and drug-host interactions. 2
• Over one-fifth of palliative care patients are inappropriately prescribed lipid-lowering medications, with two-fifths of these being for primary prevention—an indication with no benefit in this population. 2
• Prescribing in palliative care is often driven by disease guidelines rather than a rational, patient-centered approach—this must be avoided. 2

When NOT to Apply Standard Guidelines

• The ESC/EAS guidelines recommending aggressive LDL-C targets (<1.8 mmol/L or 70 mg/dL for very high-risk patients) explicitly do not apply to palliative care populations. 1
• Guidelines for heart failure patients state that cholesterol-lowering therapy with statins is not recommended in the absence of other indications. 1
• Dialysis-dependent CKD patients without atherosclerotic CVD should not have statins initiated—a similar principle applies to palliative care patients. 1

Practical Implementation

Medication Reconciliation

• Review all current medications with the patient and family, explaining that simplification of the medication regimen aligns with comfort-focused care. 1
• Discontinue statins, ezetimibe, fibrates, and other lipid-lowering agents unless the patient specifically requests continuation. 1
• Avoid routine lipid monitoring, as results will not change management and testing itself may cause discomfort. 1

Communication Strategy

• Initiate conversations with the patient and care partners regarding goals and intensity of care, explaining that strict lipid management does not improve comfort or quality of life in this setting. 1
• Frame discontinuation as appropriate medical care rather than "giving up," emphasizing the shift toward symptom management and dignity preservation. 1