Our healthcare system remains focused on acute — emergency — care and the “therapeutic imperative” to fix everything we can fix when a patient is ill. But when someone is approaching the end of life, this approach may no longer be what the patient and their families need or want most. And it may mean many patients at the end of life are not receiving 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. More significantly, it can also lead to the avoidance of comfort medications for patients who may be experiencing extreme stress or pain.
A person with advanced lung cancer is probably not going to benefit from a medication that lowers cholesterol, but they may benefit from a drug that treats pain or shortness of breath, for example. 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 medical interventions, including medications, are also costly to the healthcare system.
Canadians are living longer and the accumulation of chronic illnesses as people age has led to an increased use of pharmaceutical drugs for chronic conditions, such as diabetes or high blood pressure. The Canadian Institutes of Health Information (CIHI) reports that medications account for the second largest component of healthcare spending after hospitals — approximately $29 billion dollars per year.
If we look specifically at pharmaceutical drug use in senior populations there is a clear and steady increase in the number of chronic conditions treated. More than half of seniors in Canada are on medications to treat two or more chronic conditions. A quarter of Canadian seniors are on medications to treat three or more conditions.
When looking at the number of claims from publicly funded drug programs, there’s a corresponding increase in the number of pharmaceutical drugs taken. Over 60 percent of Canadian seniors take five or more drugs from different drug classes and over 20 percent have claims for 10 or more per year. A whopping 30 percent of those over the age of 85 claim 10 or more drugs.
There is no denying that modern medicines have improved the quantity and quality of our lives. But what should we do with chronic medications as the end of life nears?
A recent study is looking into just that question. At the Canadian Frailty Network and the University Health Network (UHN) 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 medical 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 substitute decision maker and medication changes are made with their consent.
The response among the 60 patients involved in the study to date has been overwhelmingly positive. Patients and their family caregivers are happy to receive expert recommendations that stop medications that are no longer helpful.
It was once believed that patients themselves would get upset if a doctor suggested they stop taking a long-standing medication — as if it were an admission of defeat or a sign the doctor was giving up on a patient. On the contrary; patients and family members in our study ask a lot of questions and are comfortable voicing their concerns or disagreement. The patients’ voice then becomes part of the process and helps to improve end-of-life care.
Too, the concern that that some patients would feel as though doctors were simply trying to save money by stopping their medications has also proven to be unfounded. Our study has found so far 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 the patient and family about symptoms, fears, support needs and treatment preferences can identify important ways our healthcare system can 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 Scientific Director of Canadian Frailty Network, a national not-for profit network funded by the Network of Centers on Excellence, dedicated to improving medical treatment and care options for frail elderly Canadians.