What medications can be discontinued or reduced in a patient with a complex medical history transitioning to end-of-life care?

Medication Discontinuation in End-of-Life Care

In a patient transitioning to end-of-life care, you should immediately discontinue all medications that aim to prolong life or prevent future complications, focusing exclusively on symptom management and comfort. 1

Medications to Discontinue Immediately

Preventive/Disease-Modifying Agents (No Symptom Benefit)

• Synthroid (levothyroxine 175 mcg): Discontinue—thyroid replacement has no role in EOL care and takes weeks to months for any theoretical benefit 1, 2, 3
• Colestid (colestipol): Discontinue—bile acid sequestrant for cholesterol has no immediate symptom benefit and may worsen medication absorption 2, 3
• Enoxaparin (80 mg daily): Discontinue—anticoagulation for Factor V Leiden prophylaxis provides no comfort benefit and increases bleeding risk 2, 3
• Ferrous sulfate: Discontinue—iron supplementation for anemia of 46 has no immediate benefit and commonly causes constipation, which worsens comfort 3
• Fluticasone nasal spray: Discontinue—allergy prevention has no role in EOL symptom management 3
• Fluticasone-salmeterol inhaler: Discontinue—COPD controller medication for prevention, not acute symptom relief; use albuterol PRN only for dyspnea 1, 3

Cardiovascular Medications (No Immediate Comfort Benefit)

• Amlodipine (5 mg BID): Discontinue—blood pressure control is irrelevant in dying patients and may cause hypotension 1, 2, 3
• Losartan (50 mg BID): Discontinue—same rationale as amlodipine; no comfort benefit 1, 2, 3
• Torsemide (20 mg daily): Already on hold appropriately—diuretics may worsen hypotension and have no comfort benefit when patient is dying 2

Gastrointestinal Medications (Minimal Benefit)

• Protonix (pantoprazole 20 mg): Discontinue—GERD prophylaxis is unnecessary when oral intake is declining 2, 3
• Creon (pancrelipase): Discontinue—pancreatic enzyme replacement is irrelevant when oral intake ceases 2, 3

Diabetes Medications (High Risk, No Benefit)

• NovoLOG (insulin aspart sliding scale): Discontinue—tight glycemic control is harmful in EOL care; hyperglycemia does not cause acute symptoms, but hypoglycemia causes severe distress 1
• Insulin glargine (both 5 units and 45 units): Discontinue—same rationale; allow blood sugars to run 150-300 mg/dL to avoid hypoglycemia 1

Urological Medications

• Flomax (tamsulosin 0.4 mg): Discontinue—urinary retention management becomes irrelevant; if retention causes discomfort, place indwelling catheter instead 2

Medications to Continue for Symptom Management

Pain and Dyspnea Control

• Acetaminophen 650 mg Q4H PRN: Continue—provides mild analgesia without opioid side effects 1, 4
• Pregabalin 75 mg TID: Continue initially, then reassess—provides neuropathic pain control but may cause sedation; consider discontinuing if swallowing becomes difficult 1
• Albuterol nebulizer TID: Continue PRN only—use for acute dyspnea episodes, not scheduled 1

Psychiatric Symptom Management

• Clonazepam 0.5 mg BID: Continue with extreme caution—provides anxiety control but has black box warning for respiratory depression when combined with opioids; consider transitioning to PRN dosing 5, 4
• Lamotrigine (150 mg total daily): Discontinue—mood stabilizer for bipolar disorder has no acute symptom benefit and takes weeks for effect 2

Secretion Management

• Scopolamine patch Q3 days: Continue—specifically indicated for death rattle and excess secretions in dying patients 1, 4

Sleep Aid

• Melatonin 15 mg QHS: Discontinue—excessive dose with no evidence for benefit in EOL care; if sleep disturbance causes distress, use low-dose lorazepam PRN instead 2

Critical Medication Additions Needed

This patient lacks adequate opioid therapy for EOL symptom management. 1

Opioid Initiation

• Start morphine 2-5 mg IV/SC Q2H PRN for pain or dyspnea, with continuous infusion if requiring frequent boluses 1
• Titrate aggressively without dose ceiling—opioid dose should not be reduced for decreased blood pressure or respiratory rate when necessary for symptom control 1
• Consider fentanyl instead if renal dysfunction develops, as it lacks active metabolites 6

Benzodiazepine for Refractory Symptoms

• Add lorazepam 0.5-1 mg IV/SC Q4H PRN for anxiety or dyspnea unresponsive to opioids 1, 4

Delirium Management

• Add haloperidol 0.5-2 mg IV/SC Q4-8H PRN for agitation or delirium 1, 4

Route of Administration Changes

As swallowing function declines, transition all medications to subcutaneous, transdermal, or sublingual routes. 1, 4, 7

• The subcutaneous route is preferred for most medications in actively dying patients (used in 94% at day of death) 7
• Discontinue all oral medications when patient can no longer swallow safely 4

Monitoring Discontinuation

Stop all non-comfort-oriented monitoring immediately, including blood glucose checks, blood pressure monitoring, and routine vital signs. 1

• Monitor only for signs of distress using physical assessment (grimacing, tachypnea >35/min, accessory muscle use, agitation) 1
• Document rationale for each medication given using specific symptom criteria 1

Common Pitfalls to Avoid

• Do not continue statins, vitamins, or supplements—these were continued in 15.8% and 11.6% of dying patients respectively, providing zero comfort benefit 3
• Do not continue subcutaneous heparin—used inappropriately in 29.9% of dying patients with no benefit 3
• Do not undertitrate opioids due to vital sign changes—respiratory depression is not a concern when treating refractory dyspnea or pain in dying patients 1
• Avoid abrupt benzodiazepine cessation—taper clonazepam if discontinuing, as sudden withdrawal can cause seizures and death 1, 5