EXECUTIVE SUMMARY

Nonessential medications often are continued in actively dying hospitalized patients, found a recent study. Some ethical concerns include the following:

• patients experience discomfort with no possible benefit;

• high-cost medications are administered, with no benefit;

• clinicians are taking time that could be used for patient care.

Nonessential medications, such as vitamins, often are continued in actively dying, hospitalized patients, concluded a recent study.¹

“Quite frankly, it seems to be a lack of common sense,” says lead author F. Amos Bailey, MD, FACP, FAAHPM.

The research was a secondary analysis of data from the Best Practices for End-of-Life Care for Our Nation’s Veterans (BEACON) trial, an intervention to align care for the imminently dying in inpatient settings with care patients would receive in a hospice setting.²

“It has been noted that most people say that they would want hospice care at the end of life,” says Bailey, a professor of palliative medicine at the University of Colorado Anschutz Medical Campus in Aurora.

For a variety of reasons, many still die in inpatient settings such as acute care hospitals or nursing homes. A minority die in hospice or palliative care settings. Some hospital and nursing homes have addressed this by designating hospice and palliative care sections or beds.

“Our goal was to support primary palliative care and comfort care for the imminently dying in any location in the hospital or nursing home,” says Bailey.

The BEACON researchers implemented a Comfort Care Order Set to ensure that:

• patients had orders for comfort-focused medications (opioids for pain and dyspnea; antipsychotics for delirium and nausea/vomiting; benzodiazepines for anxiety, agitation, and seizures; and medications for death rattle);

• low, frequent dosing was used as needed;

• alternative routes such as sublingual or subcutaneous were used instead of oral or IV routes if necessary;

• a comfortable environment was provided with fewer restraints, fewer IVs, fewer feeding tubes, and fans for shortness of breath.

“We noted anecdotally that many patients we consulted on were still taking medications that we would consider nonessential,” says Bailey. Often, the researchers would find cups of these medications at the bedside because the patient was unable to take them.

“We suggested to teams and nurses that this may be a sign of imminent dying,” says Bailey.

The researchers did not require providers to stop any specific treatment before switching to comfort care. However, they did instruct providers that all interventions should be reviewed. “We thought it was more important to try to make sure comfort measures were available and used,” explains Bailey.

Data on medication use was analyzed from electronic medical records of 5,476 deceased veterans. Some key findings include the following:

• five nonessential medications (clopidogrel, donepezil, glyburide, metformin, and propoxyphene) were ordered rarely (less than 5% of cases);

• simvastatin, calcium tablets, multivitamins, ferrous sulfate, diphenhydramine, and subcutaneous heparin were ordered commonly.

“We were surprised that these medications were continued at such high rates,” says Bailey.

One-third of dying patients received heparin injections, which are costly and painful to inject; one-sixth received cholesterol medications. About 10% of patients were given iron, calcium, and/or multivitamins on the day they died. “These are huge pills that even people in good health sometimes have trouble swallowing,” says Bailey.

Patients who died in an ICU were more likely to receive a nonessential medication, as were older patients. Patients who received a palliative care consult, had a DNR order placed, or were given medications for death rattle were less likely to receive a nonessential medication.

“Healthcare providers recognized these patients to be imminently dying, which prompted them to de-prescribe some of these medications,” says Bailey.

The study’s findings were not surprising to Bryan Pilkington, PhD, director of academic programs at Fordham University’s Center for Ethics Education in Bronx, NY: “There remains disagreement over what constitutes appropriate care as a patient approaches the final stages of dying.”

Giving truly unnecessary medications that could be used for other patients is an ethical concern. However, says Pilkington, if the medications do aid the dying patient, then administration should be continued: “Providing substandard treatment, even with the good aim of providing scarce resources to other patients, is not morally acceptable.”

Bailey sees these additional ethical concerns if nonessential medications are continued for imminently dying patients:

• It exposes the patient to discomfort from injections and pill burden, particularly with hard-to-swallow medications, when there can be no possible benefit.

“These are examples where there is only burden without potential positive gain,” says Bailey. “This is clearly not beneficence in action.”

• Cost of the medications, and for nursing staff, pharmacy, and others involved in their administration, is significant.

“This is not trivial,” says Bailey. “It is easier to calculate the cost of medications than the cost of the effort to continue to administer.”

• The practice distracts healthcare providers and family from truly helpful and supportive care for the patient and family.

“The hour spent crushing and trying to coax a dying patient to swallow a calcium pill in pudding is an hour not available to attend to the true care needs of patients,” says Bailey.

REFERENCES

1. Williams BR, Bailey FA, Kvale E, et al. Continuation of non-essential medications in actively dying hospitalised patients. BMJ Support Palliat Care 2017; 7(4):450-457.

2. Bailey FA, Williams BR, Woodby LL, et al. Intervention to improve care at life’s end in inpatient settings: The BEACON trial. J Gen Intern Med 2014; 29(6): 836–843.

SOURCES

• F. Amos Bailey, MD, FACP, FAAHPM, Professor of Palliative Medicine, University of Colorado Anschutz Medical Campus, Aurora. Phone: (303) 724-9674. Email: amos.bailey@ucdenver.edu.

• Bryan Pilkington, PhD, Director of Academic Programs at Fordham University’s Center for Ethics Education, Fordham University, Bronx, NY. Phone: (718) 817-0926. Email: bpilkington1@fordham.edu.