The ‘Surprise question’ in heart failure: a prospective cohort study

ObjectiveThe Surprise Question (SQ) is a prognostic screening tool used to identify patients with limited life expectancy. We assessed the SQ’s performance predicting 1-year mortality among patients in ambulatory heart failure (HF) clinics. We determined that the SQ’s performance changes according to sex and other demographic (age) and clinical characteristics, mainly left ventricular ejection fraction (LVEF) and the New York Heart Association (NYHA) functional classifications.MethodsWe conducted a prospective cohort study in two HF clinics. To assess the performance of the SQ in predicting 1-year mortality, we calculated the sensitivity, specificity, positive and negative likelihood ratios, and the positive and negative predictive values. To illustrate if the results of the SQ changes the probability that a patient dies within 1 year, we created Fagan’s nomograms. We report the results from the overall sample and for subgroups according to sex, age, LVEF and NYHA functional class.ResultsWe observed that the SQ showed a sensitivity of 85% identifying ambulatory patients with HF who are in the last year of life. We determined that the SQ’s performance predicting 1-year mortality was similar among women and men. The SQ performed better for patients aged under 70 years, for patients with reduced or mildly reduced ejection fraction, and for patients NYHA class III/IV.ConclusionsWe consider the tool an easy and fast first step to identify patients with HF who might benefit from an advance care planning discussion or a referral to palliative care due to limited life expectancy.

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

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

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

Patients 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.

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

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.

Deprescribing tool for use in older Australians with life-limiting illnesses and limited life expectancy: a modified-Delphi study protocol

BackgroundMaking a meaningful decision on deprescribing of potentially inappropriate medications in older adults with life-limiting illnesses (LLIs) and limited life expectancy (LLE) is often challenging. Therefore, we aimed to elicit opinion and gain consensus on a deprescribing tool for use in this population.Methods and analysisA modified-Delphi method will be used to obtain a consensus from a panel of experts in geriatric therapeutics on a deprescribing tool for use in people aged ≥65 years with LLIs and LLE. Through an online survey, in the initial round, the panel will anonymously elicit their opinion on a series of items related to the conceptual model of the deprescribing tool, its practicality and deprescribing of medications, while on the controlled feedback in subsequent rounds till a consensus is reached or the panellists stop revising their answers. In each round, panel members will be using a 5-point Likert scale to rate their agreement with the statement. Consensus will be considered on ≥75% of agreement on the statements.Ethics and disseminationAll the participants will receive an invitation and participant information but they need to consent for the participation. Ethics approval has been granted from the University of Queensland Health and Behavioural Sciences, Low and Negligible Risk Ethics Sub-Committee (reference: 2020001069). The results of this project will be disseminated through conferences and a peer-reviewed clinical journal.

Deprescribing in Older Adults With Cancer and Limited Life Expectancy: An Integrative Review

Polypharmacy is common in older adults with cancer and deprescribing potentially inappropriate medications becomes very relevant when life expectancy decreases due to metastatic disease. Especially preventive medications may no longer be beneficial, because they may decrease quality of life and reduction in morbidity and mortality may be futile. Although deprescribing of preventive medication is common in the last period of life, it is still unusual during active cancer treatment for advanced disease, although life expectancy is often limited to less than 1 to 2 years in that stage. We performed a systematic search of the literature in Pubmed and Embase on the discontinuation of commonly utilized groups of preventive medication and evaluated the evidence of potential benefits and harms in patients aged 65 years or older with cancer and a limited life expectancy (LLE). From 21 included studies, it can be concluded that deprescribing lipid lowering drugs, antihypertensive drugs, osteoporosis drugs and antihyperglycemic drugs is feasible in a considerable part of patients with a LLE. Discontinuation may be performed safely, without the occurrence of serious adverse events or decrease of survival. The only study that addressed quality of life after deprescribing showed that discontinuation of statins improves quality of life in patients with a LLE. Recurrence of symptoms requiring reintroduction occurred in 0-13% of patients on antihyperglycemic treatment and 8-60% of patients using antihypertensive drugs. In order to reduce pill burden and futile treatment clinicians should discuss deprescribing of preventive medication with older patients with advanced cancer and a LLE.

The role of VES-13 to identify limited life expectancy in older adults in primary healthcare settings

ABSTRACT Objective To investigate the potential role of the Vulnerable Elders Survey to identify older adults with limited life expectancy in primary healthcare settings. Method This cross-sectional study was performed in all (nine) healthcare units in Jatai, Goiás (Brazil) from July to December 2018. A sample size of 407 older adults was obtained considering an older population (≥ 60 years old). Participants answered a questionnaire about sociodemographic and clinical characteristics, including the Vulnerable Elders Survey and the Suemoto index. We tested the association between limited life expectancy and the Vulnerable Elders Survey using multiple logistic regression analysis. Results The mean age was 68.9 ± 6.6 yo, and 58.0% were women. The mean score of the Vulnerable Elders Survey was 2.0 ± 2.2, the mean score of Suemoto index was 31.5 ± 21.1%, and 17.2% had limited life expectancy. The Vulnerable Elders Survey was associated with limited life expectancy (OR = 1.57; p = < 0.0001). Conclusion The Vulnerable Elders Survey was able to identify older adults with limited life expectancy in primary healthcare settings and can play a role in detecting older adults who would not benefit from screening and strict control of chronic diseases.