1. Discontinuing Medications: Dialogues for Nurses, Physicians, Patients & Families Allison M. Webb, RPh, PharmD, CGP Clinical Pharmacist HospiScript, a Catamaran Company T&NMHO Annual Conference April 26, 2014

2. Objectives Identify principles of decision making about drug treatment in end of life care Describe strategies for communicating discontinuation of medications with patients/caregivers Describe communication strategies when addressing changes or discontinuing medications with healthcare providers

3. Why Is This Important? Medication risk outweighs benefit Lack of evidence to support continuation of therapy Does not meet patient plan of care Therapeutic benefit is diminished Polypharmacy Meeting Conditions of Participation (CoP) requirements for Medicare

4. Why Is This Important? Cost of therapy For patients & families For hospice Hospice medication coverage and hospice payment structures

5. Discontinuing Medication Late in Life Prioritize based on the following information: Remaining life expectancy Time until benefit Goals of care Treatment targets

6. A Model for Appropriate Prescribing Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9.

7. Medication Evaluation The Medication Appropriateness Index: Indication? Effective? Correct dose and directions? Practical directions? Interactions? (with drugs or disease states) Duplications? Duration acceptable? Less expensive alternative available? Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9

8. Medications: When to Stop? Medications that either: Have limited evidence to be continued at end of life o Vitamins o Statins Lose efficacy as the disease trajectory changes o Acetylcholinesterase inhibitors o Pulmonary medications o Anticoagulants o Antidiabetic medications

9. What Medications Could be Considered for Discontinuation?

10. Antihyperlipidemic Medications Statins could reduce risk for vascular events after about 2 years of treatment and significantly reduce cardiovascular events at 5 years of therapy No additional palliative benefit Limited prevention of atherosclerotic heart disease with short prognoses Increased pill burden: patients with difficulty swallowing May require liver function testing Potential side effects: myopathy/rhabdomyolysis

11. Anticoagulants Evaluate: Indication Prognosis Route of administration Bleeding risk Nutritional status Appropriate monitoring Medication adherence Medication changes Patient/family preferences Image via Google Images: http://www.dreamstime.com/stock-photography-bleeding-finger-image2490032http://www.dreamstime.com/stock-photography-bleeding-finger-image2490032 Will a new clot impair patient’s function or quality of life?

12. Anticoagulants Prepare the patient and family Discuss “early” Provide options for potential changes in therapy Educate on patient decline (to help patient and family make their decision) o Decreased renal function o Decreased nutritional intake o Swallowing status o Increased bleeding risk

13. Dementia Medications Typically, dementia has progressed beyond the point of benefit with these agents when: Patient has declined rapidly despite therapy Patient is no longer able to regularly make their needs known and/or ambulate by themselves Patient can no longer complete activities of daily living (ADLs) without assistance Functional Assessment Staging (FAST) score has progressed to a 7b or greater

14. Dementia Medications Appropriateness of these medications should be evaluated routinely Discussions should include: o Goals of care o Perceived benefit of treatment o Patient prognosis o FAST score o Eventual discontinuation when no longer beneficial

15. Dementia Medications What if there is resistance from family members? o Try a trial of a decreased dose and monitor for changes in the patient’s status or symptoms o If no change or improvement witnessed with decreased dose, the medication is no longer providing benefit and could be discontinued Should you titrate doses when discontinuing? o May consider titration, if possible o If patient is not swallowing, it may be appropriate to stop abruptly

16. Anti-Diabetic Medications The American Diabetes Association and the American Geriatric Society have stated that blood sugars need not be held to less than 180-200mg/dL for patients near the end of life. Many clinicians set the threshold at 250mg/dL. Tight glycemic control (fasting glucose <= 110mg/dL) near end-of-life carries the risk of hypoglycemic episodes Managing blood sugar to 180-250mg/dL allows for lower doses or elimination of anti-diabetic medication and reduces risk of hypoglycemia

17. Bisphosphonates It is not necessary to treat osteoporosis in hospice patients Esophageal erosions can occur if not taken with a full glass of water with patient remaining straight up for 30-60 minutes after administration Potential residual therapeutic effect after discontinuation appears to be sustained 2-5 years Patients should take calcium and vitamin D supplementation during therapy

18. Pulmonary Medications Major concerns: Inability to properly use inhalers o Inhaler technique o Cognition Over utilization of beta-agonists and anticholinergics o Duplications of therapy o Increased risk of adverse effects

19. Pulmonary Medications Signs and symptoms that a patient may have poor inhaler technique: Thrush Pneumonia Exacerbation Increased utilization Bed bound Agitation or delirium

20. Pulmonary Medications End stage respiratory cycle Over use of beta-agonists and anticholinergics leads to increased systemic absorption and CNS stimulation Increases in release of catecholamines leads to increases in HR, decrease in oxygen exchange, and anxiety = Shortness of Breath Image via Google images http://healthplusmi.kramesonline.com/Medications/3,C,82484http://healthplusmi.kramesonline.com/Medications/3,C,82484

21. Vitamins and Supplements Limited evidence to be continued at end of life Offer little or no additional palliative benefit Increased pill burden o Troublesome for patients with difficulty swallowing Increased potential for drug-drug interactions o Calcium and iron can decrease absorption of other medications o Many herbal supplements increase bleeding risk with concomitant anticoagulants/anti-platelet medications Increased potential for side effects o Iron supplements can worsen constipation and nausea

22. Vitamins and Supplements When might it be appropriate to continue vitamins and supplements? Folic acid during methotrexate therapy Thiamine and folic acid during acute alcohol withdrawal syndrome Iron supplementation during erythropoietin- stimulating agent therapy Image via Google Images: http://s3.amazonaws.com/rapgenius/10235172-close-up-of-a-spoon-full-of-pills.jpghttp://s3.amazonaws.com/rapgenius/10235172-close-up-of-a-spoon-full-of-pills.jpg

23. Medications That May Need Tapering Anti-depressants o Paroxetine (Paxil®) and venlafaxine (Effexor®) are most difficult to discontinue o Fluoxetine (Prozac®) may not require taper because of long half-life Anti-psychotics o May need to taper one while titrating up another o Gradual dose reductions Anti-epileptics o Taper after new agent is at effective dose o Regardless of use for seizures, neuropathy, or behaviors

24. Medications That May Need Tapering Beta-blockers o Taper over 1-2 weeks Clonidine (Catapres®) o Taper over 1 week o If also taking beta-blocker, taper beta-blocker first Tizanidine (Zanaflex®) o Taper over 1-2 weeks if on longer term, higher doses Baclofen o Taper over 1-2 weeks

25. Medications That May Need Tapering Corticosteroids, benzodiazepines, opioids All three classes should be tapered Unusual to discontinue in hospice Equivalent dosing strategies allow for rotation to alternative agents Ask for assistance from your medical director and/or pharmacist

26. What If There’s No Time to Taper? Be alert to side effects of abrupt withdrawal: o Rebound hypertension, tachycardia o Agitation o Seizures o Pain o Nausea o Sweating Rely on supportive care and comfort meds Contact medical director or pharmacist if concerned

27. How Do You Have These Conversations? Communicating with patients, families, and other practitioners about letting go of medications

28. Communication Barriers Patient sense of abandonment Fear of losing control Fear of losing hope Importance of maintaining attending physician relationship Cultural concerns – Who is decision-maker? – Herbal supplements, home remedies?

29. How Do These Discussions Occur? Patient Centered Care Building Understanding Informing Listening Developing

30. The BUILD Model B: Build a foundation of trust and respect. U: Understand what the patient and caregiver know about the medication and disease progression. I: Inform the patient and caregiver of evidence-based information. L: Listen to the patient’s and caregiver’s goals and expectations. D: Develop a plan of care (POC) in collaboration with the patient and caregiver.

31. B-BUILD A foundation of trust and respect with the patient and caregiver Goal: affirm the patient and caregiver; listen more than you talk.

32. B-BUILD A foundation of trust and respect with the patient and caregiver Key phrases: “Thank you for taking the time to talk with me.” “You do a great job advocating for your mother.” “As you know, cancer doesn’t just happen to the patient; it impacts the entire family. This must be very difficult for you.”

33. U – Understand What the patient and caregiver know about the medication, disease Goal: learn the patient’s and caregivers’ understanding and expectations of the medications. Ask open-ended questions Facilitate the patient/family drawing their own conclusion that the medicine may no longer be effective

34. U – Understand What the patient and caregiver know about the medication, disease Key phrases: “What has your doctor told you about how this medicine works? “What do you think your mother will look like when the medicine is no longer effective? “How will you know it’s time to stop or change the medicine?”

35. I – Inform The patient and caregiver about appropriateness of medications Goal: provide evidence-based information in a non-threatening, non-coercive way.

36. I – Inform The patient and caregiver about appropriateness of medications Key phrases: “Here’s what we know about this medicine.” “As your disease progresses we will probably need to make some changes in your medications. What worked before may not work now.” “There are other medications that may be more helpful for you at this time.”

37. L – Listen To the patient and caregiver as they share goals and expectations Goal: learn what is important to the patient and family.

38. L – Listen To the patient and caregiver as they share goals and expectations Key phrases: “How can I be of help to you at this time?” “We can’t reverse or cure your disease, but there are many things we can do to provide comfort and quality-of-life. What does quality of life look like to you?” “Did your mother ever share her thoughts about what she would want if she had dementia?”

39. D – Develop A POC in collaboration with the patient and caregiver Goal: empower the patient/caregiver to direct their care Increases compliance with the POC Offers choices for the patient and caregiver

40. D – Develop A POC in collaboration with the patient and caregiver Key phrases: “Here are some choices: we can continue with the current regimen and not make any changes. Or, we can decrease the Aricept and re-evaluate your mother’s condition in one week.” “My job is not to make decisions for you, but to provide you with information so that you can make informed decisions. What questions do you have about what we’ve talked about?” “We will work in collaboration with you and your doctor. S/he still guides your care."

41. Planned Discussions At time of admission Prior to recertification During a family or facility care conference When it’s time to re-order a medication that is regarded as delaying disease progression or no longer effective, i.e. riluzole, donepezil When filling the patient’s pillbox or ordering refills

42. Planned Discussions Change in location or level of care due to a change in patient condition: o Transfer to inpatient unit (IPU) o Transfer to an extended-care facility (ECF) o Continuous care initiated Whenever there is a need to change medications due to patient condition: o Patient having difficulty swallowing o Patient less responsive

43. Windows of Opportunity Seizing the moment: “He takes pills all day long. No wonder he doesn’t have an appetite.” “It takes 20 minutes to get his pills in him.” “I’m having to use my inhaler more often, sometimes every 2 hours.” “I can’t even walk to the door anymore because I’m so short of breath.” “Mom doesn’t even say my name anymore.”

44. Windows of Opportunity Creating the moment: “You take a lot of medications, I’m wondering if some may be causing side effects?” “With so many medications, I’m wondering if you ever prioritize the ones that are most important and skip others.” “I’m wondering if it’s difficult for you to think about discontinuing medications that your mother has taken for a long time.”

45. BUILD: Clinician Communication Patient Centered Care Building Understanding Informing Listening Developing

46. BUILD: Clinician Communication Collaboration with clinician Trust as a skilled practitioner o Both of you are doing the best for the patient Respect for the patient/prescriber relationship o Affirm the prescriber’s efforts, knowledge and commitment to the patient Evidence-based practices o Ask questions in IDT Information on patient condition o Paint a clear, succinct picture

47. Mrs. Shirley 80 y/o with lymphoma, anemia Primary caregiver for husband with dementia Recently stopped chemotherapy and considering hospice admission for extra help at home Weak, tired, short of breath Hgb not improving despite use of erythropoesis stimulating agent, Procrit® How can you use the BUILD model to start a conversation about discontinuing Procrit®?

48. Mrs. Shirley Your discussion with Mrs. Shirley was effective, and she has agreed to stop Procrit® How can you use components of the BUILD model to effectively communicate with the prescriber?

49. Summary Evaluate every medication for appropriateness Use resources to practice evidence-based medicine Practice effective communication Use the BUILD Model as a tool o Build, Understand, Inform, Listen, Develop!

50. Questions? Allison M. Webb, RPh, PharmD, CGP awebb@hospiscript.com

51. References & Further Readings Holmes HM. Reconsidering medication appropriateness for patients late in life. Arch Intern Med 2006;166:605-9. Back A, Arnold R, Tulsky J. Mastering communication with seriously ill patients: balancing honesty with empathy and hope. New York: Cambridge University Press; 2009. Lautrette A, Darmon M, Megarbane B, et al. Communication strategy and brochure for relatives of dying patients in the ICU. N Engl J Med 2007;356:469-78. Jackson VA, Back AL. Teaching communication skills using role-play: an experience-based guide for educators. J Palliat Med 2011;14(6):775-80. US Admin on Aging. The art of active listening. Aging I&R/A Tips. Tip Sheet 1. National Aging Information & Referral Support Center. 2005. Available from: http://www.mitoaction.org/pdf/tipActiveListening.pdf Buckman R. Practical plans for difficult conversations in medicine: strategies that work best in breaking bad news. Baltimore, MD: Johns Hopkins Press; 2010. National Health System (NHS) Trust. Difficult conversations: guidelines for staff. King’s Health Partners; 2011. Available from: http://www.gsttcharity.org.uk/media/4294/difficult_conversations_booklet_final.pdf Cramer C. How to have difficult conversations with patients, families. Oncology Nursing Society, 37 th Annual Congress. Silveria MJ, Kazanis AS, Shevrin MP. Statins in the last six months of life: a recognizable, life-limiting condition does not decrease their use. J Palliat Med. 2008;11(5):685-93. American College of Chest Physicians Evidence‐Based Clinical Practice Guidelines: Antithrombic therapy and prevention of thrombosis, 9th ed. Chest. 2012; 141(2_suppl), p7s‐690s. Available from: http://journal.publications.chestnet.org/

52. References & Further Readings Noble SIR, Nelson A, Finlay IG. Factors influencing hospice thromboprophylaxis policy: a qualitative study. Palliative medicine. 2008;22:808-813. Hill RR, Martinez KD, Delate T, et al. A descriptive evaluation of warfarin use in patients receiving hospice or palliative care services. J Thromb Thrombolysis. 2009;27:334-339. Winblad B, et al. Donepezil in patients with severe Alzheimer’s disease: double-blind, parallel-group, placebo-controlled study. Lancet 2006;367:1057–65. Qaseem A, Snow V, Cross Jr. JT, et al. Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med. 2008;148:370‐378. Weschules DJ, Maxwell TL, Shega JW. Acetylcholinesterase Inhibitor and N‐Methyl‐D‐Aspartic Acid Receptor Antagonist Use among Hospice Enrollees with a Primary Diagnosis of Dementia. J Palliat Med. 2008;11(5):738‐745. AACE Diabetes Care Plan Guidelines, Endocr Pract, 2011;17(Suppl 2). American Diabetes Association (2010). Position Statement: Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 33,Suppl 1, S5-S10. DOI: 10.2337/diacare.27.2007.S5. Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in elderly patient with chronic obstructive pulmonary disease. Am J Health Syst Pharm. 2011;68:1221-1232. End Stage COPD Guidance Document. HospiScript Servies, LLC. 2013. Common oral medications that may need tapering. Pharmacists Letter 2008;24:241208 Collier KS, Kimbrel JM, Protus BM. Medication appropriateness at end of life: a new tool for balancing medicine and communication for optimal outcomes-the BUILD Model. Home Healthc Nurse 2013;31(9):518-24.