Perceptions and Attitudes at End of Life in Georgia: The Similarities Regardless of the Causes of Limited Life Expectancy - Cancer or Advanced Age

Objective: Older people approaching the end of life are at a high risk for adverse drug reactions. Approaching the end of life should change the therapeutic aims, triggering a reduction in the number of drugs.The main aim of this study is to describe the preventive and symptomatic drug treatments prescribed to patients discharged with a limited life expectancy from internal medicine and geriatric wards. The secondary aim was to describe the potentially severe drug-drug interactions (DDI). Materials and Methods: We analyzed Registry of Polytherapies Societa Italiana di Medicina Interna (REPOSI), a network of internal medicine and geriatric wards, to describe the drug therapy of patients discharged with a limited life expectancy. Results: The study sample comprised 55 patients discharged with a limited life expectancy. Patients with at least 1 preventive medication that could be considered for deprescription at the end of life were significantly fewer from admission to discharge (n = 30; 54.5% vs. n = 21; 38.2%; p = 0.02). Angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, lipid-lowering drugs, and clonidine were the most frequent potentially avoidable medications prescribed at discharge, followed by xanthine oxidase inhibitors and drugs to prevent fractures. Thirty-seven (67.3%) patients were also exposed to at least 1 potentially severe DDI at discharge. Conclusion: Hospital discharge is associated with a small reduction in the use of commonly prescribed preventive medications in patients discharged with a limited life expectancy. Cardiovascular drugs are the most frequent potentially avoidable preventive medications. A consensus framework or shared criteria for potentially inappropriate medication in elderly patients with limited life expectancy could be useful to further improve drug prescription.

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Physicians' Opinions on Anticoagulant Therapy in Patients with a Limited Life Expectancy

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0041-1725115 ◽

2021 ◽

Author(s):

Bregje A.A. Huisman ◽

Eric C.T. Geijteman ◽

Nathalie Kolf ◽

Marianne K. Dees ◽

Lia van Zuylen ◽

...

Keyword(s):

Quality Of Life ◽

Decision Making ◽

Life Expectancy ◽

End Of Life ◽

Bleeding Complications ◽

Mixed Method Research ◽

Limited Life Expectancy ◽

Limited Life ◽

Increased Risk

AbstractPatients with a limited life expectancy have an increased risk of thromboembolic and bleeding complications. Anticoagulants are often continued until death, independent of their original indication. We aimed to identify the opinions of physicians about the use of anticoagulants at the end of life. A mixed-method research design was used. A secondary analysis was performed on data from a vignette study and an interview study. Participants included general practitioners and clinical specialists. Physicians varied in their opinions: some would continue and others would stop anticoagulants at the end of life because of the risk of thromboembolic or bleeding complications. The improvement or preservation of patients' quality of life was a reason for both stopping and continuing anticoagulants. Other factors considered in the decision-making were the types of anticoagulant, the indication for which the anticoagulant was prescribed, underlying diseases, and the condition and life expectancy of the patient. Factors that made decision-making difficult were the lack of evidence on either strategy, uncertainty about patients' life expectancy, and the fear of harming patients. Which decision was eventually made seems largely dependent on the choice of the patient. In conclusion, there is a substantial variation in physicians' opinions regarding the use of anticoagulants in patients with a limited life expectancy. Physicians agree that the primary goal of medical care at end of life is the improvement or preservation of patients' quality of life. An important barrier to decision-making is the lack of evidence about the risks and benefits of stopping anticoagulants.

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End of life care for frail older people; do we have a consensus guideline on deprescribing?

10.22541/au.162511832.26793696/v1 ◽

2021 ◽

Author(s):

Arjun Poudel ◽

Shakti Shrestha ◽

Anna Lukacisinova ◽

Lisa Nissen

Keyword(s):

Older Adults ◽

Life Expectancy ◽

Older People ◽

End Of Life ◽

End Of Life Care ◽

Life Care ◽

Frail Older People ◽

Limited Life Expectancy ◽

Limited Life ◽

Medication Appropriateness

Background: Deprescribing interventions have shown to improve medication appropriateness in older people. However, the evidence on the actual benefits and risks of deprescribing in older adults at the end of life are limited. Due to the lack of evidence on the safety and efficacy of medication in these populations, the most appropriate deprescribing approach is unclear. We aimed to conduct a narrative review of research on existing deprescribing guidelines targeted to frail older people at the end of life. Methods: A literature search was conducted in PubMed, Embase, CINAHL and Google Scholar to identify studies from inception to January 2021 on deprescribing guidelines/tools for frail older adults near end-of-life or palliative situation or life-limiting illnesses or limited life expectancy were included. Results: A total of nine studies were included. The deprescribing guidelines used in these studies were helpful to some extent in optimising medications in patients with limited life expectancy and life-limiting illnesses. Some of them have been tested in prospective studies that showed their usefulness in minimising the number of potentially inapproapriate medications. These studies however were not randomised and involved small sample sizes and had little insight into the clinical outcomes of using these tools. Conclusions: The existing tools and guidelines on deprescribing do not represent the end of life care nor address the medication appropriateness among individuals with a specific condition. An explicit and rigorous consensus-based guideline needs to be developed and tested in a well-designed clinical trial to measure clinically significant outcomes

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Methodological Challenges for Epidemiologic Studies of Deprescribing at the End of Life

Current Epidemiology Reports ◽

10.1007/s40471-021-00264-7 ◽

2021 ◽

Author(s):

Jennifer Tjia ◽

Jennifer L. Lund ◽

Deborah S. Mack ◽

Attah Mbrah ◽

Yiyang Yuan ◽

...

Keyword(s):

Life Expectancy ◽

End Of Life ◽

Epidemiologic Studies ◽

Potentially Inappropriate Medications ◽

Limited Life Expectancy ◽

Patient Goals ◽

Limited Life ◽

Medication Dose ◽

Selection Of

Abstract Purpose of Review To describe approaches to measuring deprescribing and associated outcomes in studies of patients approaching end of life (EOL). Recent Findings We reviewed studies published through 2020 that evaluated deprescribing in patients with limited life expectancy and approaching EOL. Deprescribing includes reducing the number of medications, decreasing medication dose(s), and eliminating potentially inappropriate medications. Tools such as STOPPFrail, OncPal, and the Unnecessary Drug Use Measure can facilitate deprescribing. Outcome measures vary and selection of measures should align with the operationalized deprescribing definition used by study investigators. Summary EOL deprescribing considerations include medication appropriateness in the context of patient goals for care, expected benefit from medication given life expectancy, and heightened potential for medication-related harm as death nears. Additional data are needed on how EOL deprescribing impacts patient quality of life, caregiver burden, and out-of-pocket medication-related costs to patients and caregivers. Investigators should design deprescribing studies with this information in mind.

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Who Orders Screening Mammograms in Older Women with Limited Life Expectancy?

Journal of General Internal Medicine ◽

10.1007/s11606-019-05044-0 ◽

2019 ◽

Vol 34 (12) ◽

pp. 2720-2722 ◽

Cited By ~ 1

Author(s):

Nancy L. Schoenborn ◽

Jin Huang ◽

Cynthia M. Boyd ◽

Sarah Nowak ◽

Craig E. Pollack

Keyword(s):

Life Expectancy ◽

Older Women ◽

Limited Life Expectancy ◽

Limited Life ◽

Screening Mammograms

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Drugs and prescribing in the older patient

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0058 ◽

2020 ◽

pp. 571-578

Author(s):

Miles Witham ◽

Jacob George ◽

Denis O’Mahony

Keyword(s):

Side Effects ◽

Life Expectancy ◽

Drug Metabolism ◽

Older People ◽

Drug Interactions ◽

Central Component ◽

Pharmacological Agents ◽

Limited Life Expectancy ◽

Limited Life ◽

Great Harm

The use of pharmacological agents is often a central component of medical therapy for older people. Medications can relieve symptoms, improve function, and prevent illness, but they also have the capacity to inflict great harm. Older people are at particular risk of such harms as a result of impaired homeostatic reserve, of altered drug metabolism, the presence of multimorbidity and consequent polypharmacy, which increases both exposure to potentially harmful agents and the chance of drug–drug interactions. The therapeutic priorities for older, frail people may differ when compared to younger, robust patients; limited life expectancy means that attempts to prolong life may become relatively less important than the relief of symptoms and avoidance of side effects and medication burden.

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