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 medication reconciliation and deprescribing come in. Medication reconciliation is the process of reviewing and updating the patient’s medication list to ensure accuracy and completeness. Deprescribing 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 hospice care, 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 hospice care 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
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 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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Morphine sulfate
No specific criteria
Appropriate
Opioids are indicated for moderate to severe pain in palliative care
Ondansetron
No specific criteria
Appropriate
Antiemetics are indicated for nausea and vomiting in palliative care
Dexamethasone
No specific criteria
Appropriate
Corticosteroids are indicated for appetite stimulation and symptom control in palliative care
Metformin
STOPP: Oral hypoglycemics with HbA1c < 7.5% in patients > 75 years
PIM
Metformin may cause hypoglycemia, lactic acidosis, and gastrointestinal side effects in older patients with limited life expectancy
Lisinopril
STOPP: ACE inhibitors or ARBs with systolic blood pressure < 120 mmHg in patients > 80 years
PIM
Lisinopril may cause hypotension, renal impairment, hyperkalemia, and cough in older patients with low blood pressure
Amlodipine
STOPP: Calcium channel blockers with chronic constipation
PIM
Amlodipine may cause constipation, edema, and hypotension in older patients with bowel dysfunction
Alendronate
STOPP: Bisphosphonates with life expectancy < 1 year
PIM
Alendronate may cause esophagitis, osteonecrosis of the jaw, and atypical fractures in older patients with short life expectancy
Calcium carbonate
STOPP: Calcium supplements with no specific indication
PIM
Calcium carbonate may cause hypercalcemia, constipation, and kidney stones in older patients with no osteoporosis
Vitamin D3
START: Vitamin D in patients > 65 years with recurrent falls
PPO
Vitamin D3 may prevent falls and fractures in older patients with vitamin D deficiency
Sertraline
No specific criteria
Appropriate
Antidepressants 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:
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.
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.
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.
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 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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Albuterol inhaler
No specific criteria
Appropriate
Short-acting beta-agonists are indicated for acute relief of dyspnea in COPD
Budesonide/formoterol inhaler
No specific criteria
Appropriate
Long-acting beta-agonists and inhaled corticosteroids are indicated for moderate to severe COPD
Tiotropium inhaler
No specific criteria
Appropriate
Long-acting anticholinergics are indicated for moderate to severe COPD
Prednisone
STOPP: Systemic corticosteroids for > 3 months
PIM
Prednisone may cause hyperglycemia, osteoporosis, infections, and mood changes in long-term use
Lorazepam
STOPP: Benzodiazepines for > 4 weeks
PIM
Lorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
Paroxetine
STOPP: Antidepressants with anticholinergic properties
PIM
Paroxetine may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with COPD
Acetaminophen
No specific criteria
Appropriate
Acetaminophen is a safe and effective analgesic for mild to moderate pain
Omeprazole
STOPP: Proton pump inhibitors for > 8 weeks
PIM
Omeprazole 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:
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.
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.
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.
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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Hydromorphone
No specific criteria
Appropriate
Opioids are indicated for moderate to severe pain in palliative care
Fentanyl patch
No specific criteria
Appropriate
Opioids are indicated for moderate to severe pain in palliative care
Gabapentin
No specific criteria
Appropriate
Anticonvulsants are indicated for neuropathic pain in palliative care
Ibuprofen
STOPP: Non-steroidal anti-inflammatory drugs (NSAIDs) with history of peptic ulcer disease or gastrointestinal bleeding
PIM
Ibuprofen may cause peptic ulcer, gastrointestinal bleeding, renal impairment, and fluid retention in older patients with gastrointestinal risk factors
Docusate sodium
STOPP: Laxatives for > 1 week
PIM
Docusate sodium may cause diarrhea, electrolyte imbalance, and dependence in long-term use
Senna
No specific criteria
Appropriate
Stimulant laxatives are indicated for opioid-induced constipation in palliative care
Metoclopramide
STOPP: Metoclopramide for > 5 days
PIM
Metoclopramide may cause extrapyramidal symptoms, tardive dyskinesia, and cardiac arrhythmias in long-term use
Haloperidol
No specific criteria
Appropriate
Antipsychotics are indicated for refractory nausea and vomiting in palliative care
Tamoxifen
STOPP: Hormonal therapies with life expectancy < 1 year
PIM
Tamoxifen may cause thromboembolism, endometrial cancer, and hot flashes in older patients with short life expectancy
Letrozole
STOPP: Hormonal therapies with life expectancy < 1 year
PIM
Letrozole 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:
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.
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.
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.
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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Memantine
STOPP: Cholinesterase inhibitors or memantine with severe dementia (MMSE < 10)
PIM
Memantine may cause headache, dizziness, confusion, and agitation in older patients with severe dementia
Donepezil
STOPP: Cholinesterase inhibitors or memantine with severe dementia (MMSE < 10)
PIM
Donepezil may cause nausea, diarrhea, bradycardia, and syncope in older patients with severe dementia
Citalopram
STOPP: Antidepressants with anticholinergic properties
PIM
Citalopram may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with dementia
Lorazepam
STOPP: Benzodiazepines for > 4 weeks
PIM
Lorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
Acetaminophen
No specific criteria
Appropriate
Acetaminophen is a safe and effective analgesic for mild to moderate pain
Nitrofurantoin
STOPP: Nitrofurantoin with renal impairment (CrCl < 60 mL/min)
PIM
Nitrofurantoin may cause pulmonary toxicity, hepatotoxicity, and peripheral neuropathy in older patients with renal impairment
Cranberry extract
STOPP: Herbal remedies with no proven efficacy
PIM
Cranberry extract may cause gastrointestinal upset, kidney stones, and drug interactions in older patients with no evidence of UTI prevention
Multivitamin tablet
STOPP: Vitamin supplements with no specific indication
PIM
Multivitamin 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:
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.
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.
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.
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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Furosemide
No specific criteria
Appropriate
Loop diuretics are indicated for fluid overload in heart failure
Spironolactone
No specific criteria
Appropriate
Aldosterone antagonists are indicated for fluid overload in heart failure
Carvedilol
STOPP: Beta-blockers with New York Heart Association (NYHA) class IV heart failure
PIM
Carvedilol may cause hypotension, bradycardia, and worsening of heart failure in patients with severe heart failure
Lisinopril
STOPP: ACE inhibitors or ARBs with systolic blood pressure < 120 mmHg in patients > 80 years
PIM
Lisinopril may cause hypotension, renal impairment, hyperkalemia, and cough in older patients with low blood pressure
Digoxin
STOPP: Digoxin for heart failure with normal sinus rhythm
PIM
Digoxin may cause arrhythmias, toxicity, and increased mortality in patients with heart failure and normal sinus rhythm
Warfarin
STOPP: Warfarin for atrial fibrillation with a CHA2DS2-VASc score of 0 in men or 1 in women
PIM
Warfarin may cause bleeding, bruising, and drug interactions in patients with low stroke risk
Escitalopram
No specific criteria
Appropriate
Selective serotonin reuptake inhibitors (SSRIs) are indicated for depression in palliative care
Mirtazapine
No specific criteria
Appropriate
Antidepressants with sedative properties are indicated for depression and insomnia in palliative care
Lorazepam
STOPP: Benzodiazepines for > 4 weeks
PIM
Lorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
Morphine sulfate
No specific criteria
Appropriate
Opioids 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:
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.
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.
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.
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 amyotrophic lateral sclerosis (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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Riluzole
STOPP: Riluzole with forced vital capacity < 50%
PIM
Riluzole may cause liver toxicity, neutropenia, and nausea in patients with severe respiratory impairment
Baclofen
No specific criteria
Appropriate
Muscle relaxants are indicated for spasticity in ALS
Diazepam
STOPP: Benzodiazepines for > 4 weeks
PIM
Diazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
Amitriptyline
STOPP: Antidepressants with anticholinergic properties
PIM
Amitriptyline may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with ALS
Morphine sulfate
No specific criteria
Appropriate
Opioids are indicated for pain in palliative care
Omeprazole
STOPP: Proton pump inhibitors for > 8 weeks
PIM
Omeprazole may cause hypomagnesemia, osteoporosis, infections, and rebound acid hypersecretion in long-term use
Polyethylene glycol 3350
No specific criteria
Appropriate
Osmotic laxatives are indicated for constipation in palliative care
Senna
No specific criteria
Appropriate
Stimulant 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:
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.
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.
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.
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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Levodopa/carbidopa
No specific criteria
Appropriate
Dopamine precursors are indicated for motor symptoms in Parkinson’s disease
Pramipexole
STOPP: Dopamine agonists with history of hallucinations or confusion
PIM
Pramipexole may cause hallucinations, confusion, impulse control disorders, and orthostatic hypotension in older patients with psychosis
Amantadine
STOPP: Amantadine with history of seizures or heart failure
PIM
Amantadine may cause seizures, cardiac arrhythmias, peripheral edema, and anticholinergic effects in older patients with neurological or cardiac risk factors
Quetiapine
STOPP: Antipsychotics with Parkinson’s disease
PIM
Quetiapine may cause extrapyramidal symptoms, tardive dyskinesia, sedation, and increased mortality in older patients with Parkinson’s disease
Lorazepam
STOPP: Benzodiazepines for > 4 weeks
PIM
Lorazepam may cause sedation, confusion, falls, dependence, and withdrawal in long-term use
Paroxetine
STOPP: Antidepressants with anticholinergic properties
PIM
Paroxetine may cause dry mouth, constipation, urinary retention, and cognitive impairment in older patients with Parkinson’s disease
Acetaminophen
No specific criteria
Appropriate
Acetaminophen is a safe and effective analgesic for mild to moderate pain
Bisacodyl
No specific criteria
Appropriate
Stimulant 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:
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.
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.
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.
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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Bicalutamide
STOPP: Hormonal therapies with life expectancy < 1 year
PIM
Bicalutamide may cause gynecomastia, hot flashes, liver toxicity, and fatigue in older patients with short life expectancy
Leuprolide
STOPP: Hormonal therapies with life expectancy < 1 year
PIM
Leuprolide may cause osteoporosis, hot flashes, diabetes, and cardiovascular events in older patients with short life expectancy
Zoledronic acid
STOPP: Bisphosphonates with life expectancy < 1 year
PIM
Zoledronic acid may cause hypocalcemia, renal impairment, osteonecrosis of the jaw, and atypical fractures in older patients with short life expectancy
Morphine sulfate
No specific criteria
Appropriate
Opioids are indicated for moderate to severe pain in palliative care
Ibuprofen
STOPP: Non-steroidal anti-inflammatory drugs (NSAIDs) with history of peptic ulcer disease or gastrointestinal bleeding
PIM
Ibuprofen may cause peptic ulcer, gastrointestinal bleeding, renal impairment, and fluid retention in older patients with gastrointestinal risk factors
Ondansetron
No specific criteria
Appropriate
Antiemetics are indicated for nausea and vomiting in palliative care
Dexamethasone
No specific criteria
Appropriate
Corticosteroids are indicated for appetite stimulation and symptom control in palliative care
Ferrous sulfate
STOPP: Iron supplements with no specific indication
PIM
Ferrous sulfate may cause constipation, nausea, and drug interactions in older patients with no iron deficiency
Folic acid
STOPP: Folic acid supplements with no specific indication
PIM
Folic acid may cause masking of vitamin B12 deficiency, seizures, and drug interactions in older patients with no folate deficiency
Cyanocobalamin
START: Vitamin B12 in patients > 65 years with macrocytic anemia
PPO
Cyanocobalamin 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:
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.
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.
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.
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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Spironolactone
No specific criteria
Appropriate
Aldosterone antagonists are indicated for ascites in liver cirrhosis
Furosemide
No specific criteria
Appropriate
Loop diuretics are indicated for ascites in liver cirrhosis
Propranolol
STOPP: Beta-blockers with systolic blood pressure < 100 mmHg
PIM
Propranolol may cause hypotension, bradycardia, and worsening of liver function in patients with low blood pressure
Lactulose
No specific criteria
Appropriate
Osmotic laxatives are indicated for hepatic encephalopathy in liver cirrhosis
Rifaximin
No specific criteria
Appropriate
Antibiotics are indicated for hepatic encephalopathy in liver cirrhosis
Acetaminophen
STOPP: Acetaminophen > 2 g/day with chronic liver disease
PIM
Acetaminophen may cause hepatotoxicity and liver failure in patients with liver impairment
Ondansetron
No specific criteria
Appropriate
Antiemetics are indicated for nausea in palliative care
Pantoprazole
STOPP: Proton pump inhibitors for > 8 weeks
PIM
Pantoprazole 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:
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.
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.
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.
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:
Medication
START/STOPP Criteria
PIM or PPO
Rationale
Erythropoietin
STOPP: Erythropoiesis-stimulating agents with hemoglobin > 11 g/dL or life expectancy < 1 year
PIM
Erythropoietin may cause hypertension, thromboembolism, and increased mortality in older patients with high hemoglobin or short life expectancy
Iron sucrose
STOPP: Iron supplements with no specific indication
PIM
Iron sucrose may cause hypotension, anaphylaxis, and iron overload in older patients with no iron deficiency
Folic acid
STOPP: Folic acid supplements with no specific indication
PIM
Folic acid may cause masking of vitamin B12 deficiency, seizures, and drug interactions in older patients with no folate deficiency
Sevelamer
STOPP: Phosphate binders with serum phosphate < 1.8 mmol/L
PIM
Sevelamer may cause nausea, vomiting, constipation, and drug interactions in older patients with low serum phosphate
Calcitriol
STOPP: Vitamin D analogues with serum calcium > 2.6 mmol/L or life expectancy < 1 year
PIM
Calcitriol may cause hypercalcemia, vascular calcification, and increased mortality in older patients with high serum calcium or short life expectancy
Amlodipine
No specific criteria
Appropriate
Calcium channel blockers are indicated for hypertension in renal failure
Metoprolol
No specific criteria
Appropriate
Beta-blockers are indicated for hypertension in renal failure
Simvastatin
STOPP: Statins with life expectancy < 1 year
PIM
Simvastatin may cause myopathy, rhabdomyolysis, and drug interactions in older patients with short life expectancy
Acetaminophen
No specific criteria
Appropriate
Acetaminophen is a safe and effective analgesic for mild to moderate pain
Morphine sulfate
No specific criteria
Appropriate
Opioids 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:
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.
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.
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.
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.
