Why should life‑prolonging medications be discontinued in an elderly palliative patient with advanced cancer, end‑stage organ failure, or severe frailty and limited life expectancy?

Why Life-Prolonging Medications Should Be Discontinued in Palliative Patients

Life-prolonging medications should be discontinued in palliative patients because they provide no mortality or quality-of-life benefit when life expectancy is limited, while increasing pill burden, adverse drug events, and suffering without addressing the primary goal of comfort care. 1, 2

The Fundamental Shift in Treatment Goals

When patients transition to palliative care with limited life expectancy (months to weeks or less), the treatment paradigm must fundamentally change from disease modification to symptom control and quality of life optimization. 3, 1 This is not "giving up"—rather, it represents "fighting for better quality of life" as recommended by the National Comprehensive Cancer Network. 1, 2

• For patients with months to weeks of life expectancy, anticancer therapy and disease-modifying treatments should be discontinued because they no longer provide meaningful benefit relative to their burdens. 3, 1
• For patients with weeks to days remaining, the National Comprehensive Cancer Network explicitly recommends discontinuing anticancer therapy in favor of intensive palliative care focusing on symptom control. 3, 1

Why Preventive Medications Become Inappropriate

Time-to-Benefit Mismatch

The core issue is that preventive medications require months to years to demonstrate benefit, but palliative patients have weeks to months of remaining life. 3, 4

• Statins for cardiovascular prevention require 2-5 years to reduce mortality risk—yet research shows over one-quarter of patients continue receiving statins even one week before death. 4
• Aspirin for cardiovascular prevention similarly requires extended time horizons, yet one-third of patients were still prescribed aspirin one week before death. 4
• Antihypertensives, diabetes medications, and osteoporosis treatments all target long-term complications that will never manifest within the patient's remaining lifespan. 3

Increased Harm Without Benefit

Continuing preventive medications in palliative patients creates a harmful risk-benefit ratio:

• Polypharmacy burden: Palliative patients average 10 total medications one week before death when preventive drugs are continued, increasing to 7.5 medications seven days before death. 5, 4
• Adverse drug events: Polypharmacy is associated with drug interactions, toxicity, falls, delirium, and nonadherence—all particularly dangerous in frail, dying patients. 3
• Pill burden and costs: Unnecessary medications add physical burden (difficulty swallowing pills), financial costs, and complexity without addressing comfort needs. 6, 7

Systematic Approach to Medication Discontinuation

Step 1: Identify Medications Eligible for Deprescribing

The STOPPFrail 2021 criteria specifically address patients with end-stage irreversible pathology, poor 1-year survival prognosis, and severe functional impairment—these medications should be stopped or not started: 3

• Cardiovascular prevention: Statins, aspirin, antihypertensives (when not needed for symptom control)
• Diabetes medications: Especially those targeting long-term complications (not acute hyperglycemia symptoms)
• Osteoporosis treatments: Bisphosphonates, denosumab
• Anticoagulants for primary/secondary prevention: Unless treating symptomatic thrombosis
• Proton pump inhibitors: Unless treating active symptomatic GERD
• Any medication without clear symptom-control indication 3

Step 2: Consider Remaining Life Expectancy

The framework for discontinuation decisions depends on prognosis: 3, 1

• Years to months: Begin discussing goals of care and reassessing appropriateness of preventive medications
• Months to weeks: Actively discontinue medications with long time-to-benefit; focus on symptom management
• Weeks to days: Discontinue all non-comfort medications; intensify palliative symptom control

Step 3: Safe Discontinuation Protocol

Critical caveat: Certain drug classes require cautious tapering to avoid withdrawal syndromes, particularly cardiovascular and central nervous system medications. 3, 1

• Generally stop one medication at a time to monitor for withdrawal effects or symptom changes. 3
• Medications requiring caution: Beta-blockers, benzodiazepines, antidepressants, anticonvulsants, corticosteroids, opioids (if reducing—though opioids should typically be maintained or increased for symptom control). 3, 1
• Medications that can be stopped abruptly: Statins, aspirin (in most cases), bisphosphonates, vitamins, most diabetes medications. 3

What Medications Should Be Continued or Initiated

The focus shifts entirely to symptom management: 1, 2

• Opioids: For pain and dyspnea management—doses should NOT be reduced for vital sign changes when needed for symptom control. 1, 2
• Benzodiazepines: For anxiety and sedation. 1
• Antipsychotics: For delirium (haloperidol, risperidone, olanzapine, quetiapine). 2
• Antiemetics: For nausea and vomiting. 8
• Corticosteroids: For specific symptom control (tumor-related bowel obstruction, dyspnea, appetite). 8

Evidence Supporting Deprescribing in Palliative Care

Research demonstrates that deprescribing occurs too late in the dying process:

• A retrospective study of 149 older adults in palliative care showed medication adaptation only occurred during the last week of life, with 79.3% having at least one unnecessary drug deprescribed and 75.2% having essential symptom-control drugs added. 5
• The mean number of medications actually increased from 6.7 drugs at 90 days before death to 7.5 drugs at 7 days before death, only dropping to 5.6 on the day of death. 5
• Studies show approximately 20% of palliative cancer patients continue receiving potentially inappropriate medications. 6
• Palliative care consultation significantly reduces potentially inappropriate medications (p < 0.001), demonstrating the positive impact of systematic deprescribing. 7

Common Pitfalls to Avoid

Pitfall 1: Continuing Medications "Just in Case"

Clinicians may fear liability regarding underuse of therapies and continue medications even when benefit is unclear—this represents misplaced caution that prioritizes theoretical legal risk over patient comfort. 3

Pitfall 2: Delaying Deprescribing Until the Final Days

Evidence shows medication rationalization typically occurs only in the last week of life, meaning patients endure unnecessary pill burden and adverse effects for weeks to months. 5 Deprescribing should begin when prognosis shifts to months, not days.

Pitfall 3: Assuming Patients Understand Their Prognosis

The National Comprehensive Cancer Network specifically recommends confirming patient understanding of disease incurability and reassessing understanding of goals of therapy and prognosis for all patients with months to weeks to live. 3, 2 Many patients do not fully process prognostic information, leading to continued inappropriate expectations for life-prolonging treatments.

Pitfall 4: Reducing Opioids for Vital Sign Changes

Never reduce opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate management of dyspnea and pain. 1, 2 Symptom control takes priority over vital sign parameters in dying patients.

Pitfall 5: Failing to Document Decision-Making

Decisions to stop medications should be made after careful discussion with the patient and family, with clear documentation of the rationale and alignment with patient goals. 3 This protects against misunderstanding and provides continuity across care transitions.

The Ethical Framework

Withholding or withdrawing ineffective, futile, burdensome, and unnecessary life-prolonging treatments is ethically appropriate and does not constitute euthanasia or physician-assisted suicide. 1 The intent is to reduce suffering and medication burden, not to hasten death. This distinction is critical for clinician comfort with deprescribing and for patient/family understanding.