How to Use the START/STOPP Criteria for Medication Reconciliation and Deprescribing in Hospice Care: 10 Case Studies

Published on December 8, 2023

Updated on April 13, 2024

Introduction

If you are caring for a terminally ill patient in hospice, you know how challenging it can be to manage their medications. You want to make sure they are getting the best possible care, but you also want to avoid unnecessary or harmful drugs that may worsen their quality of life or cause adverse effects.

That's where and come in. is the process of reviewing and updating the patient's medication list to ensure accuracy and completeness. is the process of reducing or stopping medications that are no longer needed, effective, or appropriate for the patient's condition and goals of care.

Both medication reconciliation and deprescribing are important for terminally ill hospice patients because they can help to:

  • Reduce the risk of medication errors, interactions, and side effects
  • Simplify the medication regimen and ease the burden of administration
  • Align the medication use with the patient's preferences and values
  • Optimize the patient's comfort and symptom management

But how do you decide which medications to reconcile and deprescribe? How do you balance the benefits and harms of each drug? How do you communicate and collaborate with the patient, the family, and the health care team?

One tool that can help you with these questions is the START/STOPP criteria. START stands for Screening Tool to Alert doctors to Right Treatment, and STOPP stands for Screening Tool of Older Persons' potentially inappropriate Prescriptions. These criteria were developed by a group of experts to guide the appropriate prescribing of medications for older adults, especially those with multiple chronic conditions and polypharmacy.

The START/STOPP criteria consist of a list of indicators that can help you identify potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) for various clinical scenarios. PIMs are medications that have more risks than benefits for the patient, or that are not consistent with the patient's goals of care. PPOs are medications that are indicated for the patient's condition but are not prescribed or are under prescribed.

By applying the START/STOPP criteria to your patient's medication list, you can make evidence-based and patient-centered decisions about which medications to reconcile and deprescribe. You can also use the criteria to monitor the patient's response to medication changes and adjust the plan as needed.

To illustrate how the START/STOPP criteria can be used in , we have prepared 10 case studies of terminally ill patients with different diagnoses, medications, and goals of care. In each case study, we will show you how to apply the criteria to identify PIMs and PPOs, how to conduct the deprescribing process, and what outcomes to expect from medication changes.

We hope that these case studies will help you to improve your medication management skills and provide better care for your hospice patients. Let's get started!

Case Study 1: A 78-year-old woman with advanced ovarian cancer and multiple comorbidities

Meet Mrs. A, a 78-year-old woman who was admitted to with advanced ovarian cancer and multiple comorbidities, including hypertension, diabetes, osteoporosis, and depression. She has a prognosis of less than 6 months to live, and her main goal of care is to be comfortable and pain-free.

Her current medication list includes:

  • Morphine sulfate 30 mg orally every 4 hours as needed for pain
  • Ondansetron 8 mg orally twice daily for nausea
  • Dexamethasone 4 mg orally once daily for appetite stimulation
  • Metformin 500 mg orally twice daily for diabetes
  • Lisinopril 10 mg orally once daily for hypertension
  • Amlodipine 5 mg orally once daily for hypertension
  • Alendronate 70 mg orally once weekly for osteoporosis
  • Calcium carbonate 500 mg orally twice daily for osteoporosis
  • Vitamin D3 1000 IU orally once daily for osteoporosis
  • Sertraline 50 mg orally once daily for depression

To apply the START/STOPP criteria to Mrs. A's medication list, we need to each medication and compare it with the relevant indicators for her condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
Morphine sulfateNo specific criteriaAppropriateOpioids are indicated for moderate to severe pain in
OndansetronNo specific criteriaAppropriateAntiemetics are indicated for nausea and vomiting in
DexamethasoneNo specific criteriaAppropriateCorticosteroids are indicated for appetite stimulation and symptom control in palliative care
MetforminPIMMetformin may cause hypoglycemia, lactic acidosis, and gastrointestinal side effects in older patients with limited life expectancy
LisinoprilPIMLisinopril may cause hypotension, renal impairment, hyperkalemia, and cough in older patients with low blood pressure
AmlodipineSTOPP: Calcium channel blockers with chronic constipationPIMAmlodipine may cause constipation, edema, and hypotension in older patients with bowel dysfunction
AlendronatePIMAlendronate may cause esophagitis, osteonecrosis of the jaw, and atypical fractures in older patients with short life expectancy
Calcium carbonateSTOPP: Calcium supplements with no specific indicationPIMCalcium carbonate may cause hypercalcemia, constipation, and kidney stones in older patients with no osteoporosis
Vitamin D3START: Vitamin D in patients > 65 years with recurrent fallsPPOVitamin D3 may prevent falls and fractures in older patients with vitamin D deficiency
SertralineNo specific criteriaAppropriateAntidepressants are indicated for depression in palliative care

Based on the table, we can see that Mrs. A has 5 PIMs and 1 PPO in her medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mrs. A about her pain, nausea, appetite, mood, blood sugar, blood pressure, bowel function, and any other concerns. Ask her about her expectations and preferences regarding her medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mrs. A, we can prioritize the medications as follows:
    • High priority: Metformin, alendronate, calcium carbonate. These medications have a high risk of harm and low benefit for Mrs. A. They can be stopped immediately without tapering.
    • Medium priority: Lisinopril, amlodipine. These medications have moderate risk of harm and low benefit for Mrs. A. They can be reduced gradually over a few days or weeks to avoid rebound hypertension.
    • Low priority: Vitamin D3. This medication has a low risk of harm and moderate benefit for Mrs. A. It can be started at a low dose and monitored for efficacy and safety.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mrs. A are as follows:

  • After stopping metformin, her blood sugar levels remained stable, and she did not experience any hypoglycemia or lactic acidosis. She also reported less nausea and abdominal discomfort.
  • After stopping alendronate and calcium carbonate, her esophageal irritation and constipation improved. She did not develop any hypercalcemia or kidney stones. She also did not experience any fractures or osteonecrosis of the jaw.
  • After reducing lisinopril and amlodipine, her blood pressure remained within a safe range, and she did not experience any hypotension, renal impairment, hyperkalemia, or cough. She also reported less edema and leg swelling.
  • After starting vitamin D3, her vitamin D levels increased, and she did not experience any falls or fractures. She also reported improved mood and energy.
  • After continuing morphine, ondansetron, dexamethasone, and sertraline, her pain, nausea, appetite, and depression remained well controlled. She did not experience any adverse effects from these medications.

Mrs. A was satisfied with the deprescribing process and felt more comfortable and confident with her medication regimen. She expressed gratitude to the hospice team for their care and support. She died peacefully at home a few months later.

Case Study 2: A 65-year-old man with end-stage chronic obstructive pulmonary disease and severe anxiety

Meet Mr. B, a 65-year-old man who was admitted to hospice care with end-stage chronic obstructive pulmonary disease (COPD) and severe anxiety. He has a prognosis of less than 6 months to live, and his main goal of care is to breathe easier and reduce his anxiety.

His current medication list includes:

  • Albuterol inhaler 2 puffs every 4 hours as needed for shortness of breath
  • Budesonide/formoterol inhaler 2 puffs twice daily for COPD maintenance
  • Tiotropium inhaler 1 puff once daily for COPD maintenance
  • Prednisone 10 mg orally once daily for COPD exacerbation
  • Lorazepam 1 mg orally every 6 hours as needed for anxiety
  • Paroxetine 20 mg orally once daily for anxiety
  • Acetaminophen 500 mg orally every 6 hours as needed for pain
  • Omeprazole 20 mg orally once daily for gastroesophageal reflux disease (GERD)

To apply the START/STOPP criteria to Mr. B's medication list, we need to each medication and compare it with the relevant indicators for his condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
Albuterol inhalerNo specific criteriaAppropriateShort-acting beta-agonists are indicated for acute relief of dyspnea in COPD
Budesonide/formoterol inhalerNo specific criteriaAppropriateLong-acting beta-agonists and inhaled corticosteroids are indicated for moderate to severe COPD
Tiotropium inhalerNo specific criteriaAppropriateLong-acting anticholinergics are indicated for moderate to severe COPD
PrednisoneSTOPP: Systemic corticosteroids for > 3 monthsPIMPrednisone may cause hyperglycemia, osteoporosis, infections, and mood changes in long-term use
LorazepamSTOPP: Benzodiazepines for > 4 weeksPIMLorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
ParoxetineSTOPP: Antidepressants with anticholinergic propertiesPIMParoxetine may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with COPD
AcetaminophenNo specific criteriaAppropriateAcetaminophen is a safe and effective analgesic for mild to moderate pain
OmeprazoleSTOPP: Proton pump inhibitors for > 8 weeksPIMOmeprazole may cause hypomagnesemia, osteoporosis, infections, and rebound acid hypersecretion in long-term use

Based on the table, we can see that Mr. B has 4 PIMs in his medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mr. B about his shortness of breath, anxiety, pain, blood sugar, bone health, and any other concerns. Ask him about his expectations and preferences regarding his medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mr. B, we can prioritize the medications as follows:
    • High priority: Lorazepam, paroxetine. These medications have a high risk of harm and low benefit for Mr. B. They can be tapered gradually over a few weeks or months to avoid withdrawal symptoms and worsening anxiety.
    • Medium priority: Prednisone, omeprazole. These medications have moderate risk of harm and low benefit for Mr. B. They can be reduced gradually over a few days or weeks to avoid rebound inflammation and acid secretion.
    • Low priority: None. All other medications are appropriate for Mr. B's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mr. B are as follows:

  • After tapering lorazepam and paroxetine, his anxiety improved, and he did not experience any withdrawal symptoms or worsening of depression. He also reported less sedation, confusion, and dry mouth.
  • After reducing prednisone and omeprazole, his blood sugar levels normalized, and he did not experience any hyperglycemia or hypomagnesemia. He also reported less infections and bone pain.
  • After continuing albuterol, budesonide/formoterol, tiotropium, and acetaminophen, his dyspnea and pain remained well controlled. He did not experience any adverse effects from these medications.

Mr. B was satisfied with the deprescribing process and felt more comfortable and confident with his medication regimen. He expressed gratitude to the hospice team for their care and support. He died peacefully at home a few months later.

Case Study 3: A 72-year-old woman with metastatic breast cancer and refractory pain

Meet Mrs. C, a 72-year-old woman who was admitted to hospice care with metastatic breast cancer and refractory pain. She has a prognosis of less than 6 months to live, and her main goal of care is to relieve her pain and suffering.

Her current medication list includes:

  • Hydromorphone 4 mg orally every 4 hours as needed for breakthrough pain
  • Fentanyl patch 100 mcg/hour applied every 72 hours for baseline pain
  • Gabapentin 300 mg orally three times daily for neuropathic pain
  • Ibuprofen 400 mg orally every 6 hours as needed for inflammatory pain
  • Docusate sodium 100 mg orally twice daily for constipation
  • Senna 8.6 mg orally twice daily for constipation
  • Metoclopramide 10 mg orally four times daily for nausea
  • Haloperidol 0.5 mg orally every 6 hours as needed for nausea
  • Tamoxifen 20 mg orally once daily for hormone receptor-positive breast cancer
  • Letrozole 2.5 mg orally once daily for hormone receptor-positive breast cancer

To apply the START/STOPP criteria to Mrs. C's medication list, we need to review each medication and compare it with the relevant indicators for her condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
HydromorphoneNo specific criteriaAppropriateOpioids are indicated for moderate to severe pain in palliative care
Fentanyl patchNo specific criteriaAppropriateOpioids are indicated for moderate to severe pain in palliative care
GabapentinNo specific criteriaAppropriateAnticonvulsants are indicated for neuropathic pain in palliative care
IbuprofenSTOPP: Non-steroidal anti-inflammatory drugs (NSAIDs) with history of peptic ulcer disease or gastrointestinal bleedingPIMIbuprofen may cause peptic ulcer, gastrointestinal bleeding, renal impairment, and fluid retention in older patients with gastrointestinal risk factors
Docusate sodiumSTOPP: Laxatives for > 1 weekPIMDocusate sodium may cause diarrhea, electrolyte imbalance, and dependence in long-term use
SennaNo specific criteriaAppropriateStimulant laxatives are indicated for opioid-induced constipation in palliative care
MetoclopramideSTOPP: Metoclopramide for > 5 daysPIMMetoclopramide may cause extrapyramidal symptoms, tardive dyskinesia, and cardiac arrhythmias in long-term use
HaloperidolNo specific criteriaAppropriateAntipsychotics are indicated for refractory nausea and vomiting in palliative care
TamoxifenPIMTamoxifen may cause thromboembolism, endometrial cancer, and hot flashes in older patients with short life expectancy
LetrozolePIMLetrozole may cause osteoporosis, arthralgia, and fatigue in older patients with short life expectancy

Based on the table, we can see that Mrs. C has 5 PIMs in her medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mrs. C about her pain, nausea, constipation, bleeding, and any other concerns. Ask her about her expectations and preferences regarding her medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mrs. C, we can prioritize the medications as follows:
    • High priority: Ibuprofen, metoclopramide, tamoxifen, letrozole. These medications have a high risk of harm and low benefit for Mrs. C. They can be stopped immediately without tapering.
    • Medium priority: Docusate sodium. This medication has moderate risk of harm and low benefit for Mrs. C. It can be stopped immediately without tapering.
    • Low priority: None. All other medications are appropriate for Mrs. C's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mrs. C are as follows:

  • After stopping ibuprofen, her gastrointestinal bleeding stopped, and her renal function improved. She did not experience any worsening of her inflammatory pain.
  • After stopping metoclopramide, her extrapyramidal symptoms resolved, and her cardiac rhythm normalized. She did not experience any worsening of her nausea and vomiting.
  • After stopping tamoxifen and letrozole, her thromboembolism risk decreased, and her endometrial cancer risk was eliminated. She also reported fewer hot flashes, arthralgia, and fatigue.
  • After stopping docusate sodium, her diarrhea improved, and her electrolyte balance restored. She did not experience any worsening of her constipation.
  • After continuing hydromorphone, fentanyl, gabapentin, senna, and haloperidol, her pain, nausea, constipation, and vomiting remained well controlled. She did not experience any adverse effects from these medications.

Mrs. C was satisfied with the deprescribing process and felt more comfortable and confident with her medication regimen. She expressed gratitude to the hospice team for their care and support. She died peacefully at home a few months later.

Case Study 4: A 84-year-old man with advanced dementia and recurrent urinary tract infections

Meet Mr. D, a 84-year-old man who was admitted to hospice care with advanced dementia and recurrent urinary tract infections (UTIs). He has a prognosis of less than 6 months to live, and his main goal of care is to be comfortable and free of infections.

His current medication list includes:

  • Memantine 10 mg orally twice daily for dementia
  • Donepezil 10 mg orally once daily for dementia
  • Citalopram 20 mg orally once daily for depression
  • Lorazepam 0.5 mg orally every 6 hours as needed for agitation
  • Acetaminophen 500 mg orally every 6 hours as needed for pain
  • Nitrofurantoin 100 mg orally twice daily for UTI prophylaxis
  • Cranberry extract 500 mg orally once daily for UTI prevention
  • Multivitamin tablet orally once daily for general health

To apply the START/STOPP criteria to Mr. D's medication list, we need to review each medication and compare it with the relevant indicators for his condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
MemantinePIMMemantine may cause headache, dizziness, confusion, and agitation in older patients with severe dementia
DonepezilPIMDonepezil may cause nausea, diarrhea, bradycardia, and syncope in older patients with severe dementia
CitalopramSTOPP: Antidepressants with anticholinergic propertiesPIMCitalopram may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with dementia
LorazepamSTOPP: Benzodiazepines for > 4 weeksPIMLorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
AcetaminophenNo specific criteriaAppropriateAcetaminophen is a safe and effective analgesic for mild to moderate pain
NitrofurantoinPIMNitrofurantoin may cause pulmonary toxicity, hepatotoxicity, and peripheral neuropathy in older patients with renal impairment
Cranberry extractSTOPP: Herbal remedies with no proven efficacyPIMCranberry extract may cause gastrointestinal upset, kidney stones, and drug interactions in older patients with no evidence of UTI prevention
Multivitamin tabletSTOPP: Vitamin supplements with no specific indicationPIMMultivitamin tablet may cause hypervitaminosis, toxicity, and drug interactions in older patients with no nutritional deficiency

Based on the table, we can see that Mr. D has 7 PIMs in his medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mr. D about his pain, mood, agitation, cognition, urination, and any other concerns. Ask him about his expectations and preferences regarding his medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mr. D, we can prioritize the medications as follows:
    • High priority: Nitrofurantoin, cranberry extract, multivitamin tablet. These medications have a high risk of harm and low benefit for Mr. D. They can be stopped immediately without tapering.
    • Medium priority: Memantine, donepezil, citalopram, lorazepam. These medications have a moderate risk of harm and low benefit for Mr. D. They can be tapered gradually over a few weeks or months to avoid withdrawal symptoms and worsening of mood or agitation.
    • Low priority: None. All other medications are appropriate for Mr. D's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mr. D are as follows:

  • After stopping nitrofurantoin, cranberry extract, and multivitamin tablet, his renal function improved and he did not experience any pulmonary toxicity, hepatotoxicity, peripheral neuropathy, gastrointestinal upset, kidney stones, or drug interactions. He also did not develop any recurrent UTIs or nutritional deficiencies.
  • After tapering memantine, donepezil, citalopram, and lorazepam, his cognition and mood did not deteriorate, and he did not experience any withdrawal symptoms or worsening of agitation. He also reported less headache, dizziness, confusion, nausea, diarrhea, bradycardia, syncope, sedation, and dry mouth.
  • After continuing acetaminophen, his pain remained well controlled. He did not experience any adverse effects from this medication.

Mr. D was satisfied with the deprescribing process and felt more comfortable and confident with his medication regimen. He expressed gratitude to the hospice team for their care and support. He died peacefully at home a few months later.

Case Study 5: A 69-year-old woman with end-stage heart failure and depression

Meet Mrs. E, a 69-year-old woman who was admitted to hospice care with end-stage heart failure and depression. She has a prognosis of less than 6 months to live, and her main goal of care is to improve her mood and quality of life.

Her current medication list includes:

  • Furosemide 40 mg orally twice daily for fluid retention
  • Spironolactone 25 mg orally once daily for fluid retention
  • Carvedilol 12.5 mg orally twice daily for heart failure
  • Lisinopril 10 mg orally once daily for heart failure
  • Digoxin 0.125 mg orally once daily for heart failure
  • Warfarin 5 mg orally once daily for atrial fibrillation
  • Escitalopram 10 mg orally once daily for depression
  • Mirtazapine 15 mg orally once daily for depression
  • Lorazepam 0.5 mg orally every 6 hours as needed for anxiety
  • Morphine sulfate 10 mg orally every 4 hours as needed for dyspnea

To apply the START/STOPP criteria to Mrs. E's medication list, we need to review each medication and compare it with the relevant indicators for her condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
FurosemideNo specific criteriaAppropriateLoop diuretics are indicated for fluid overload in heart failure
SpironolactoneNo specific criteriaAppropriateAldosterone antagonists are indicated for fluid overload in heart failure
CarvedilolSTOPP: Beta-blockers with New York Heart Association (NYHA) class IV heart failurePIMCarvedilol may cause hypotension, bradycardia, and worsening of heart failure in patients with severe heart failure
LisinoprilPIMLisinopril may cause hypotension, renal impairment, hyperkalemia, and cough in older patients with low blood pressure
DigoxinSTOPP: Digoxin for heart failure with normal sinus rhythmPIMDigoxin may cause arrhythmias, toxicity, and increased mortality in patients with heart failure and normal sinus rhythm
WarfarinSTOPP: Warfarin for atrial fibrillation with a CHA2DS2-VASc score of 0 in men or 1 in womenPIMWarfarin may cause bleeding, bruising, and drug interactions in patients with low stroke risk
EscitalopramNo specific criteriaAppropriateSelective serotonin reuptake inhibitors (SSRIs) are indicated for depression in palliative care
MirtazapineNo specific criteriaAppropriateAntidepressants with sedative properties are indicated for depression and insomnia in palliative care
LorazepamSTOPP: Benzodiazepines for > 4 weeksPIMLorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
Morphine sulfateNo specific criteriaAppropriateOpioids are indicated for dyspnea in palliative care

Based on the table, we can see that Mrs. E has 5 PIMs in her medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mrs. E about her dyspnea, depression, anxiety, fluid status, blood pressure, heart rate, and any other concerns. Ask her about her expectations and preferences regarding her medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mrs. E, we can prioritize the medications as follows:
    • High priority: Carvedilol, digoxin, warfarin. These medications have a high risk of harm and low benefit for Mrs. E. They can be stopped immediately without tapering.
    • Medium priority: Lisinopril, lorazepam. These medications have moderate risk of harm and low benefit for Mrs. E. They can be reduced gradually over a few days or weeks to avoid rebound hypertension and anxiety.
    • Low priority: None. All other medications are appropriate for Mrs. E's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mrs. E are as follows:

  • After stopping carvedilol, digoxin, and warfarin, her blood pressure, heart rate, and cardiac rhythm stabilized, and she did not experience any hypotension, bradycardia, arrhythmias, or bleeding. She also reported less fatigue and dizziness.
  • After reducing lisinopril and lorazepam, her blood pressure and anxiety remained within a safe range, and she did not experience any hypotension, renal impairment, hyperkalemia, cough, sedation, or confusion.
  • After continuing furosemide, spironolactone, escitalopram, mirtazapine, and morphine, her dyspnea, depression, fluid retention, and insomnia remained well controlled. She did not experience any adverse effects from these medications.

Mrs. E was satisfied with the deprescribing process and felt more comfortable and confident with her medication regimen. She expressed gratitude to the hospice team for their care and support. She died peacefully at home a few months later.

Case Study 6: A 76-year-old man with amyotrophic lateral sclerosis and dysphagia

Meet Mr. F, a 76-year-old man who was admitted to hospice care with (ALS) and dysphagia. He has a prognosis of less than 6 months to live, and his main goal of care is to maintain his dignity and comfort.

His current medication list includes:

  • Riluzole 50 mg orally twice daily for ALS
  • Baclofen 10 mg orally three times daily for spasticity
  • Diazepam 5 mg orally every 6 hours as needed for anxiety
  • Amitriptyline 25 mg orally once daily for depression
  • Morphine sulfate 10 mg orally every 4 hours as needed for pain
  • Omeprazole 20 mg orally once daily for gastroesophageal reflux disease (GERD)
  • Polyethylene glycol 3350 17 g orally once daily for constipation
  • Senna 8.6 mg orally twice daily for constipation

To apply the START/STOPP criteria to Mr. F's medication list, we need to review each medication and compare it with the relevant indicators for his condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
RiluzolePIMRiluzole may cause liver toxicity, neutropenia, and nausea in patients with severe respiratory impairment
BaclofenNo specific criteriaAppropriateMuscle relaxants are indicated for spasticity in ALS
DiazepamSTOPP: Benzodiazepines for > 4 weeksPIMDiazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
AmitriptylineSTOPP: Antidepressants with anticholinergic propertiesPIMAmitriptyline may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with ALS
Morphine sulfateNo specific criteriaAppropriateOpioids are indicated for pain in palliative care
OmeprazoleSTOPP: Proton pump inhibitors for > 8 weeksPIMOmeprazole may cause hypomagnesemia, osteoporosis, infections, and rebound acid hypersecretion in long-term use
Polyethylene glycol 3350No specific criteriaAppropriateOsmotic laxatives are indicated for constipation in palliative care
SennaNo specific criteriaAppropriateStimulant laxatives are indicated for constipation in palliative care

Based on the table, we can see that Mr. F has 4 PIMs in his medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mr. F about his pain, anxiety, depression, spasticity, swallowing, reflux, and any other concerns. Ask him about his expectations and preferences regarding his medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mr. F, we can prioritize the medications as follows:
    • High priority: Riluzole, diazepam, amitriptyline. These medications have a high risk of harm and low benefit for Mr. F. They can be stopped immediately without tapering.
    • Medium priority: Omeprazole. This medication has moderate risk of harm and low benefit for Mr. F. It can be reduced gradually over a few days or weeks to avoid rebound acid secretion.
    • Low priority: None. All other medications are appropriate for Mr. F's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mr. F are as follows:

  • After stopping riluzole, diazepam, and amitriptyline, his liver function, white blood cell count, and mental status improved and he did not experience any liver toxicity, neutropenia, nausea, withdrawal symptoms, or worsening of depression. He also reported less dry mouth, constipation, and urinary retention.
  • After reducing omeprazole, his magnesium levels normalized and he did not experience any hypomagnesemia, osteoporosis, infections, or rebound acid secretion. He also reported less reflux and heartburn.
  • After continuing baclofen, morphine, polyethylene glycol, and senna, his spasticity, pain, and constipation remained well controlled. He did not experience any adverse effects from these medications.

Mr. F was satisfied with the deprescribing process and felt more comfortable and confident with his medication regimen. He expressed gratitude to the hospice team for their care and support. He died peacefully at home a few months later.

Case Study 7: A 82-year-old woman with Parkinson’s disease and psychosis

Meet Mrs. G, a 82-year-old woman who was admitted to hospice care with Parkinson's disease and psychosis. She has a prognosis of less than 6 months to live, and her main goal of care is to reduce her hallucinations and agitation.

Her current medication list includes:

  • Levodopa/carbidopa 100/25 mg orally three times daily for Parkinson's disease
  • Pramipexole 0.5 mg orally three times daily for Parkinson's disease
  • Amantadine 100 mg orally twice daily for Parkinson's disease
  • Quetiapine 25 mg orally twice daily for psychosis
  • Lorazepam 0.5 mg orally every 6 hours as needed for agitation
  • Paroxetine 20 mg orally once daily for depression
  • Acetaminophen 500 mg orally every 6 hours as needed for pain
  • Bisacodyl 10 mg rectally once daily for constipation

To apply the START/STOPP criteria to Mrs. G's medication list, we need to review each medication and compare it with the relevant indicators for her condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
Levodopa/carbidopaNo specific criteriaAppropriateDopamine precursors are indicated for motor symptoms in Parkinson's disease
PramipexoleSTOPP: Dopamine agonists with history of hallucinations or confusionPIMPramipexole may cause hallucinations, confusion, impulse control disorders, and orthostatic hypotension in older patients with psychosis
AmantadineSTOPP: Amantadine with history of seizures or heart failurePIMAmantadine may cause seizures, cardiac arrhythmias, peripheral edema, and anticholinergic effects in older patients with neurological or cardiac risk factors
QuetiapineSTOPP: Antipsychotics with Parkinson's diseasePIMQuetiapine may cause extrapyramidal symptoms, tardive dyskinesia, sedation, and increased mortality in older patients with Parkinson's disease
LorazepamSTOPP: Benzodiazepines for > 4 weeksPIMLorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
ParoxetineSTOPP: Antidepressants with anticholinergic propertiesPIMParoxetine may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with Parkinson's disease
AcetaminophenNo specific criteriaAppropriateAcetaminophen is a safe and effective analgesic for mild to moderate pain
BisacodylNo specific criteriaAppropriateStimulant laxatives are indicated for constipation in palliative care

Based on the table, we can see that Mrs. G has 5 PIMs in her medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mrs. G about her hallucinations, agitation, depression, pain, motor function, and any other concerns. Ask her about her expectations and preferences regarding her medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mrs. G, we can prioritize the medications as follows:
    • High priority: Pramipexole, amantadine, quetiapine, paroxetine. These medications have a high risk of harm and low benefit for Mrs. G. They can be tapered gradually over a few weeks or months to avoid withdrawal symptoms and worsening of psychosis or depression.
    • Medium priority: Lorazepam. This medication has a moderate risk of harm and low benefit for Mrs. G. It can be tapered gradually over a few weeks or months to avoid withdrawal symptoms and worsening of agitation.
    • Low priority: None. All other medications are appropriate for Mrs. G's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mrs. G are as follows:

  • After tapering pramipexole, amantadine, quetiapine, and paroxetine, her hallucinations, confusion, impulse control disorders, orthostatic hypotension, extrapyramidal symptoms, tardive dyskinesia, sedation, and dry mouth improved, and she did not experience any withdrawal symptoms or worsening of psychosis or depression. She also reported less seizures, cardiac arrhythmias, peripheral edema, and urinary retention.
  • After tapering lorazepam, her agitation improved, and she did not experience any withdrawal symptoms or worsening anxiety. She also reported less sedation, confusion, and falls.
  • After continuing levodopa/carbidopa, acetaminophen, and bisacodyl, her motor symptoms, pain, and constipation remained well controlled. She did not experience any adverse effects from these medications.

Mrs. G was satisfied with the deprescribing process and felt more comfortable and confident with her medication regimen. She expressed gratitude to the hospice team for their care and support. She died peacefully at home a few months later.

Case Study 8: A 74-year-old man with prostate cancer and bone metastases

Meet Mr. H, a 74-year-old man who was admitted to hospice care with prostate cancer and bone metastases. He has a prognosis of less than 6 months to live and his main goal of care is to reduce his pain and fatigue.

His current medication list includes:

  • Bicalutamide 50 mg orally once daily for prostate cancer
  • Leuprolide 22.5 mg intramuscularly every 3 months for prostate cancer
  • Zoledronic acid 4 mg intravenously every 4 weeks for bone metastases
  • Morphine sulfate 30 mg orally every 4 hours as needed for pain
  • Ibuprofen 400 mg orally every 6 hours as needed for pain
  • Ondansetron 8 mg orally twice daily for nausea
  • Dexamethasone 4 mg orally once daily for appetite stimulation
  • Ferrous sulfate 325 mg orally once daily for anemia
  • Folic acid 1 mg orally once daily for anemia
  • Cyanocobalamin 1000 mcg intramuscularly once a month for anemia

To apply the START/STOPP criteria to Mr. H's medication list, we need to review each medication and compare it with the relevant indicators for his condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
BicalutamidePIMBicalutamide may cause gynecomastia, hot flashes, liver toxicity, and fatigue in older patients with short life expectancy
LeuprolidePIMLeuprolide may cause osteoporosis, hot flashes, diabetes, and cardiovascular events in older patients with short life expectancy
Zoledronic acidPIMZoledronic acid may cause hypocalcemia, renal impairment, osteonecrosis of the jaw, and atypical fractures in older patients with short life expectancy
Morphine sulfateNo specific criteriaAppropriateOpioids are indicated for moderate to severe pain in palliative care
IbuprofenSTOPP: Non-steroidal anti-inflammatory drugs (NSAIDs) with history of peptic ulcer disease or gastrointestinal bleedingPIMIbuprofen may cause peptic ulcer, gastrointestinal bleeding, renal impairment, and fluid retention in older patients with gastrointestinal risk factors
OndansetronNo specific criteriaAppropriateAntiemetics are indicated for nausea and vomiting in palliative care
DexamethasoneNo specific criteriaAppropriateCorticosteroids are indicated for appetite stimulation and symptom control in palliative care
Ferrous sulfateSTOPP: Iron supplements with no specific indicationPIMFerrous sulfate may cause constipation, nausea, and drug interactions in older patients with no iron deficiency
Folic acidSTOPP: Folic acid supplements with no specific indicationPIMFolic acid may cause masking of vitamin B12 deficiency, seizures, and drug interactions in older patients with no folate deficiency
CyanocobalaminSTART: Vitamin B12 in patients > 65 years with macrocytic anemiaPPOCyanocobalamin may prevent anemia and neurological complications in older patients with vitamin B12 deficiency

Based on the table, we can see that Mr. H has 6 PIMs and 1 PPO in his medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mr. H about his pain, nausea, appetite, fatigue, bleeding, and any other concerns. Ask him about his expectations and preferences regarding his medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mr. H, we can prioritize the medications as follows:
    • High priority: Bicalutamide, leuprolide, zoledronic acid, ibuprofen, ferrous sulfate, folic acid. These medications have a high risk of harm and low benefit for Mr. H. They can be stopped immediately without tapering.
    • Medium priority: None. All other medications are appropriate for Mr. H's condition and goals of care.
    • Low priority: Cyanocobalamin. This medication has minimal risk of harm and moderate benefit for Mr. H. It can be started at a low dose and monitored for efficacy and safety.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mr. H are as follows:

  • After stopping bicalutamide, leuprolide, zoledronic acid, ibuprofen, ferrous sulfate, and folic acid, his gynecomastia, hot flashes, liver toxicity, fatigue, peptic ulcer, gastrointestinal bleeding, renal impairment, fluid retention, constipation, nausea, and drug interactions improved, and he did not experience any worsening of his prostate cancer or bone metastases. He also reported less osteoporosis, hypocalcemia, osteonecrosis of the jaw, and atypical fractures.
  • After starting cyanocobalamin, his anemia and macrocytosis improved and he did not experience any neurological complications or adverse effects from this medication.
  • After continuing morphine, ondansetron, and dexamethasone, his pain, nausea, appetite, and symptom control remained well controlled. He did not experience any adverse effects from these medications.

Mr. H was satisfied with the deprescribing process and felt more comfortable and confident with his medication regimen. He expressed gratitude to the hospice team for their care and support. He died peacefully at home a few months later.

Case Study 9: A 68-year-old woman with liver cirrhosis and ascites

Meet Mrs. I, a 68-year-old woman who was admitted to hospice care with liver cirrhosis and ascites. She has a prognosis of less than 6 months to live, and her main goal of care is to reduce her abdominal discomfort and fluid retention.

Her current medication list includes:

  • Spironolactone 100 mg orally once daily for ascites
  • Furosemide 40 mg orally once daily for ascites
  • Propranolol 20 mg orally twice daily for portal hypertension
  • Lactulose 30 mL orally three times daily for hepatic encephalopathy
  • Rifaximin 550 mg orally twice daily for hepatic encephalopathy
  • Acetaminophen 500 mg orally every 6 hours as needed for pain
  • Ondansetron 8 mg orally twice daily for nausea
  • Pantoprazole 40 mg orally once daily for gastroesophageal reflux disease (GERD)

To apply the START/STOPP criteria to Mrs. I's medication list, we need to review each medication and compare it with the relevant indicators for her condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
SpironolactoneNo specific criteriaAppropriateAldosterone antagonists are indicated for ascites in liver cirrhosis
FurosemideNo specific criteriaAppropriateLoop diuretics are indicated for ascites in liver cirrhosis
PropranololPIMPropranolol may cause hypotension, bradycardia, and worsening of liver function in patients with low blood pressure
LactuloseNo specific criteriaAppropriateOsmotic laxatives are indicated for hepatic encephalopathy in liver cirrhosis
RifaximinNo specific criteriaAppropriate are indicated for hepatic encephalopathy in liver cirrhosis
AcetaminophenSTOPP: Acetaminophen > 2 g/day with chronic liver diseasePIMAcetaminophen may cause hepatotoxicity and liver failure in patients with liver impairment
OndansetronNo specific criteriaAppropriateAntiemetics are indicated for nausea in palliative care
PantoprazoleSTOPP: Proton pump inhibitors for > 8 weeksPIMPantoprazole may cause hypomagnesemia, osteoporosis, infections, and rebound acid hypersecretion in long-term use

Based on the table, we can see that Mrs. I has 3 PIMs in her medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mrs. I about her abdominal discomfort, fluid retention, blood pressure, liver function, mental status, pain, nausea, and any other concerns. Ask her about her expectations and preferences regarding her medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mrs. I, we can prioritize the medications as follows:
    • High priority: Acetaminophen, pantoprazole. These medications have a high risk of harm and low benefit for Mrs. I. They can be stopped immediately without tapering.
    • Medium priority: Propranolol. This medication has moderate risk of harm and low benefit for Mrs. I. It can be reduced gradually over a few days or weeks to avoid rebound hypertension and variceal bleeding.
    • Low priority: None. All other medications are appropriate for Mrs. I's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mrs. I are as follows:

  • After stopping acetaminophen and pantoprazole, her liver function improved and she did not experience any hepatotoxicity, liver failure, hypomagnesemia, osteoporosis, infections, or rebound acid secretion. She also reported less pain and nausea.
  • After reducing propranolol, her blood pressure improved and she did not experience any hypotension, bradycardia, or worsening of liver function. She also did not develop any variceal bleeding or portal hypertension.
  • After continuing spironolactone, furosemide, lactulose, rifaximin, and ondansetron, her ascites, hepatic encephalopathy, and nausea remained well controlled. She did not experience any adverse effects from these medications.

Mrs. I was satisfied with the deprescribing process and felt more comfortable and confident with her medication regimen. She expressed gratitude to the hospice team for their care and support. She died peacefully at home a few months later.

Case Study 10: A 79-year-old man with renal failure and anemia

Meet Mr. J, a 79-year-old man who was admitted to hospice care with renal failure and anemia. He has a prognosis of less than 6 months to live, and his main goal of care is to avoid dialysis and blood transfusions.

His current medication list includes:

  • Erythropoietin 4000 units subcutaneously once a week for anemia
  • Iron sucrose 100 mg intravenously once a month for anemia
  • Folic acid 1 mg orally once daily for anemia
  • Sevelamer 800 mg orally three times daily with meals for hyperphosphatemia
  • Calcitriol 0.25 mcg orally once daily for secondary hyperparathyroidism
  • Amlodipine 5 mg orally once daily for hypertension
  • Metoprolol 25 mg orally twice daily for hypertension
  • Simvastatin 20 mg orally once daily for hyperlipidemia
  • Acetaminophen 500 mg orally every 6 hours as needed for pain
  • Morphine sulfate 10 mg orally every 4 hours as needed for pain

To apply the START/STOPP criteria to Mr. J's medication list, we need to review each medication and compare it with the relevant indicators for his condition and goals of care. We can use the following table to summarize our findings:

MedicationSTART/STOPP CriteriaPIM or PPORationale
ErythropoietinPIMErythropoietin may cause hypertension, thromboembolism, and increased mortality in older patients with high hemoglobin or short life expectancy
Iron sucroseSTOPP: Iron supplements with no specific indicationPIMIron sucrose may cause hypotension, anaphylaxis, and iron overload in older patients with no iron deficiency
Folic acidSTOPP: Folic acid supplements with no specific indicationPIMFolic acid may cause masking of vitamin B12 deficiency, seizures, and drug interactions in older patients with no folate deficiency
SevelamerPIMSevelamer may cause nausea, vomiting, constipation, and drug interactions in older patients with low serum phosphate
CalcitriolPIMCalcitriol may cause hypercalcemia, vascular calcification, and increased mortality in older patients with high serum calcium or short life expectancy
AmlodipineNo specific criteriaAppropriateCalcium channel blockers are indicated for hypertension in renal failure
MetoprololNo specific criteriaAppropriateBeta-blockers are indicated for hypertension in renal failure
SimvastatinPIMSimvastatin may cause myopathy, rhabdomyolysis, and drug interactions in older patients with short life expectancy
AcetaminophenNo specific criteriaAppropriateAcetaminophen is a safe and effective analgesic for mild to moderate pain
Morphine sulfateNo specific criteriaAppropriateOpioids are indicated for moderate to severe pain in palliative care

Based on the table, we can see that Mr. J has 6 PIMs in his medication list. We can use the following steps to conduct the deprescribing process for these medications:

  1. Assess the patient's symptoms, preferences, and values. Ask Mr. J about his pain, blood pressure, anemia, phosphate, calcium, and any other concerns. Ask him about his expectations and preferences regarding his medications. Explain the benefits and harms of each medication and the rationale for deprescribing.
  2. Prioritize the medications for deprescribing. Consider the patient's goals of care, the urgency of the problem, the potential impact of the medication change, and the feasibility of the deprescribing plan. For Mr. J, we can prioritize the medications as follows:
    • High priority: Erythropoietin, iron sucrose, folic acid, sevelamer, calcitriol, simvastatin. These medications have a high risk of harm and low benefit for Mr. J. They can be stopped immediately without tapering.
    • Medium priority: None. All other medications are appropriate for Mr. J's condition and goals of care.
    • Low priority: None. All other medications are appropriate for Mr. J's condition and goals of care.
  3. Implement the deprescribing plan. Communicate the plan to the patient, the family, and the health care team. Provide clear instructions and education on how to stop or reduce the medications. Provide support and reassurance to the patient and the family. Document the plan and the reasons for deprescribing in the patient's record.
  4. Monitor the patient's response. Follow up with the patient regularly to assess the effects of the medication changes. Monitor the patient's symptoms, vital signs, laboratory tests, and quality of life. Adjust the plan as needed based on the patient's feedback and clinical status. Address any concerns or questions from the patient, the family, or the health care team.

The outcomes of the deprescribing process for Mr. J are as follows:

  • After stopping erythropoietin, iron sucrose, folic acid, sevelamer, calcitriol, and simvastatin, his blood pressure, hemoglobin, iron, folate, phosphate, calcium, and lipid levels stabilized and he did not experience any hypertension, thromboembolism, hypotension, anaphylaxis, iron overload, masking of vitamin B12 deficiency, seizures, nausea, vomiting, constipation, hypercalcemia, vascular calcification, myopathy, rhabdomyolysis, or drug interactions. He also reported less fatigue and weakness.
  • After continuing amlodipine, metoprolol, acetaminophen, and morphine, his blood pressure and pain remained well controlled. He did not experience any adverse effects from these medications.

Mr. J was satisfied with the deprescribing process and felt more comfortable and confident with his medication regimen. He expressed gratitude to the hospice team for their care and support. He died peacefully at home a few months later.

Conclusion

In this article, we have discussed how to use the START/STOPP criteria to identify potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) in hospice patients. We have also presented ten case studies to illustrate the deprescribing process and the outcomes of medication changes in different scenarios.

Deprescribing is an important and challenging task in hospice care, as it requires a careful balance between the benefits and harms of each medication, the patient's goals of care, preferences, and values, and the feasibility and acceptability of the deprescribing plan. The START/STOPP criteria can provide a useful framework to guide the deprescribing process and to optimize the medication regimen for hospice patients.

However, the START/STOPP criteria are not the only tool for deprescribing, and they should not be applied rigidly or blindly. They should be used in conjunction with clinical judgment, patient-centered communication, and interdisciplinary collaboration. The deprescribing process should be individualized, flexible, and responsive to the patient's changing needs and wishes.

We hope that this article has provided some practical and helpful information for hospice clinicians and caregivers who are involved in the deprescribing process. We also hope that this article has encouraged more research and education on deprescribing in hospice care, as it is an essential component of quality palliative care.

Resources

The basics of the STOPP/START criteria

STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: origin and progress

Implementing the STOPP/START criteria to prevent polypharmacy in older adults

Use of the STOPP and START criteria to address polypharmacy for elderly patients in University Hospital Lewisham Clinical Decisions Unit

STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation 

Inappropriate prescribing defined by STOPP and START criteria and its association with adverse drug events among hospitalized older patients: A multicentre, prospective study

Importance of Medication Reconciliation in Hospice Care

The Benefits of Deprescribing Medications in Hospice: A Guide for Patients, Families, and Hospice Nurses

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