Withdrawing Treatment and Deprescribing

What can I do?

Align treatment with the person’s goals and wishes, which may change over time.

Check that medications (and other treatments) used to manage comorbidities continue to provide benefit to the patient as their illness progresses, while minimising any burdens or harms.

Use the STOPPFrail list of criteria to help identify potentially inappropriate medicine use in frail older adults with limited life.

Discuss withdrawal of treatments and deprescribing of medications in the context of the wishes laid out in a person’s advance care directive.

Build a relationship with the person and their family/carer prior to discussing the withdrawal of treatment or the discontinuing of medications. This requires sensitivity to the person’s physical needs, values and goals as well as consideration of the impact on family/carers.

Explain the process of withdrawal and any potential issues from the withdrawal empathetically to the person and their family/carer - withdrawing treatment does not mean withdrawing care. Reassure the person and family that all measures to provide comfort and support will be continued. This includes attention to personal care, especially oral care and symptom relief. You can use these useful phrases (110kb pdf) where applicable.

Consider if other medicines are required to ensure comfort throughout the withdrawal period.

Pharmacists may be involved with palliative care in both hospital and community settings. If relevant, ask a pharmacist to conduct a Home Medicines Review (HMR) or a Residential Medication Management Review (RMMR)

What can I learn?

STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy) Lavan AH, Gallagher P, Parsons C, O’Mahony D.  Age and ageing. 2017 Jan 23.

STOPP/START = Screening Tool of Older Persons Prescriptions/Screening Tool to Alert doctors to Right Treatment

From PHN Tasmania:

• Deprescribing resources
• Guides to the use of medicines in older people
• Rethinking Your Medications resources for consumers

Medstopper - online tool, customisable for frail patients; provides instructions for monitoring medication cessation and rebound symptom management

Medication Cessation for Adults in the Last Days of Life from SA Health

Communicating about end of life issues can be difficult; check out these resources:

• CareSearch website (free access)
• Vital Talk website (free access) including the VITALTalk Tips app
• Therapeutic Guidelines Communicating with the patient in palliative care (subscription required)

Read:

• Hilmer SN, Gnjidic D. Prescribing for frail older people. Aust Prescr. 2017 Oct;40(5):174-178.
• Pharmacovigilance in palliative care – a CPD activity for pharmacists
• Managing your medicines from NPS Medicinewise
• Therapeutic Guidelines (Palliative Care) (subscription needed)

What can my organisation do?

On admission to residential care or community service, give all clients the opportunity to discuss their wishes and treatment options at end of life. Ensure that these wishes are reviewed concurrently with a change in the care plan or with a change in the care needs.

Ensure that all new palliative clients are given the opportunity to discuss their wishes, and preferences for treatment options at end of life.

Include palliative care education in the staff development plan and ensure that all new staff are supported to be comfortable discussing end-of-life care with clients and their families.

Consider guidelines for withdrawal of medications that are no longer supporting quality of life.  Educate staff about the importance of the guidelines especially that each person is an individual with their own needs, beliefs, values that may be different to each staff and understanding and respect of each person’s individual decisions is most important.

Develop deprescribing policies for end of life to support General Practitioners and specialists as well as assuring individuals and their families that their comfort and symptom issues will be cared for.