Inappropriate Medications in the Hospice Setting

Supportive Care in Cancer recently published an article on the use of “futile” medications in patients with advanced and incurable cancer. It was a retrospective chart review of patients attending a palliative care clinic at the Princess Margaret Hospital in Toronto between November 2005 and July 2006. Futile medications were defined as either unnecessary (no benefit in terms of survival, quality of life, or symptom control for this particular population) or duplicate (drugs from the same pharmacological class). Long story made short is that about one fifth of these terminally ill patients were taking at least one futile medication, with 90% of these being medically unnecessary. Highest on the list: statins and multivitamins.

Now, one can argue that there is a good level of subjectivity to the term “futility” used in this article, as it was the studies’ authors and, as luck may have it, the palliative medicine consultant who decided when a medication was futile (any medication that the palliative care doc deemed appropriate was no longer considered futile). Convenient, yes. Is there a better way, possibly.It’s been almost two decades since the original Beers Criteriawas published. This was a list of drugs that were potentially inappropriate for elderly patients. These drugs had side effects that were thought to be far more harmful in elderly patients than any potential therapeutic benefit. In honor of the late Dr. Mark Beers, who died in March 2009, I think it would be reasonable to think about creating a similar list for hospice patients. This list will not only take in to account the risks for adverse events, but also whether medications provide any benefit in terms of survival, quality of life, or symptom control.

Here is my top three potentially inappropriate drugs for use in hospice patients:

1. Docusate (Colace): number one my list even though it’s recommended by every palliative and geriatrics text book I have ever read. Why number one? Lack of proven efficacy and risks of grave harm if given orally as a solution (or if the capsule is crushed if a patient can no longer tolerate pills). The solution is the most vile substance I have ever tasted. Even worse, the aftertaste sticks with you for about 3 hours. No wonder patients lose weight in the hospital – they all get this stuff thanks to our recommendations.
2. Statins: There is a lot of talk and hand waving out there on this one, but to sum up – no good evidence that statins are benefitial within weeks to months. The best study that showed possible early benefit after a heart attack (PROVE IT – TIMI 22) excluded patients who were likely to die within 2 years. There is also no evidence that stopping statinsin patients with chronic cardiac disease increases mortality or any other outcome except higher LDLs. Harms: another pill, myopathy, drug-drug interactions.
3. Multi-Vitamins: most of the time when I admit patients to our hospice unit on multivitamins they have been started by their physicians at some point during a hospital stay. It’s usually because they have had ongoing weight loss from their cancer, heart failure, COPD, or dementia. Getting adequate amounts of folate is great for pregnant mothers, but beyond that there is no real proven effectiveness. Harms: constipation, nausea, and a potentially unpleasant taste if crushed.

What’s your top three? I welcome the geripal community to add to this list by commenting below, or if you disagree with any of the above, tell us why.