Why patients at the end of life may not be receiving the best care

Providing comfort care should be the first priority for those nearing the end

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By James Downar
Palliative care physician
Toronto General Hospital
and John Muscedere
Expert Advisor
EvidenceNetwork.ca

TORONTO, Ont. Dec. 21, 2015/ Troy Media/ — Our health-care system focuses on fixing everything we can when a patient is ill. But when someone is nearing the end of life, this approach may no longer be what the patient and their families need or want most. And it may mean such patients don’t receive the best care.

When someone is admitted to hospital, the focus is often on reversing acute conditions rather than providing comfort care for patients, even when they have little time left. This may lead to the use of drugs or other medical interventions that offer little benefit. And, significantly, it could lead to the avoidance of comfort medications for patients in extreme stress or pain.

For example, a person with advanced lung cancer is probably not going to benefit from cholesterol medication, but they may benefit from a drug that treats pain or shortness of breath. Or a person with severe heart failure is probably not going to benefit from a medication to prevent osteoporosis, but they might benefit from medications to improve their sleep or mood.

Using non-beneficial medications or failing to offer comfort medications is potentially harmful, time-consuming and simply bad medical care. Unnecessary or unwarranted interventions, including medications, are also costly to the health-care system.

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Patients and family are happy to receive expert recommendations that stop medications that are no longer helpful

Canadians are living longer and the accumulation of chronic illnesses as people age has led to increased use of pharmaceuticals for chronic conditions, such as diabetes or high blood pressure. The Canadian Institute for Health Information reports that medications represent the second largest component of health-care spending after hospitals — approximately $29 billion a year.

There is a clear and steady increase in chronic conditions treated in seniors. More than half of Canadian seniors take medications to treat two or more chronic conditions. A quarter of seniors are on medications to treat three or more conditions.

More than 60 per cent of Canadian seniors take five or more medications from different drug classes and over 20 per cent have insurance claims for 10 or more per year. A whopping 30 per cent of those over the age of 85 claim 10 or more drugs.

Modern medicines have improved the quantity and quality of our lives. But what should we do with medications that treat chronic conditions as the end of life nears?

At the Technology Evaluation in the Elderly Network and the University Health Network in Toronto, we’ve been examining the impact of assigning a “medication rationalization” team of physicians, pharmacists and nurses to review medications prescribed to patients with advanced illness. The team makes recommendations on stopping any non-comfort medication that has no clear benefit to the patient and suggests comfort medications. These recommendations are presented to the patient or decision maker and changes are made with consent.

The response among the 60 patients involved in the study to date has been overwhelmingly positive. Patients and family are happy to receive expert recommendations that stop medications that are no longer helpful.

It was once believed that patients would get upset if a doctor suggested they stop taking a long-standing medication — as if it were an admission of defeat by patient or doctor. On the contrary, patients and family members in our study ask a lot of questions and are comfortable voicing concerns or disagreement. The patient’s voice then becomes part of the process and helps to improve end-of-life care.

The concern that some patients would feel doctors were trying to save money by stopping medications has also proven to be unfounded. Our study has found that patients are usually very comfortable stopping some medications and starting others because they also believe it is the right thing to do.

It is entirely beneficial to re-examine the goals of treatment at end of life. Even a brief conversation with patients and families about symptoms, fears, support needs and treatment preferences can identify important ways to provide better care.

James Downar is a critical care and palliative care physician at Toronto General Hospital. He is also the chair of the postgraduate education committee of the Canadian Society of Palliative Care Physicians. John Muscedere is an advisor with EvidenceNetwork.ca, a critical care physician and the scientific director for the Technology Evaluation in the Elderly Network, which is a non-for profit network funded by the National Centres on Excellence.

James and John are Troy Media contributors. Why aren’t you?


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