Medication reconciliation plays a pivotal role in hospice care, ensuring that terminally ill patients receive the most appropriate and safe medication regimens. This process involves creating and maintaining an accurate list of a patient's medications to prevent adverse drug events and enhance their overall well-being. In this article, we will delve into the importance of medication reconciliation, including its recommended frequency and the reconciliation process.

The Significance of Medication Reconciliation

Medication reconciliation is essential at various stages of hospice care, including admission, recertification, , medication changes, respite, revocation, and discharge for cause or failure to decline. Here's why it matters:

  • Preventing Medication Errors: Accurate medication reconciliation helps prevent potentially harmful medication errors, ensuring that patients receive the right drugs at the right doses.
  • Enhancing Patient Safety: By keeping an up-to-date medication list, healthcare providers can identify potential drug interactions or contraindications, thereby enhancing patient safety.
  • Optimizing Symptom Management: Terminally ill patients often experience multiple symptoms. Proper medication reconciliation ensures that their symptom management is as effective as possible.

In terms of highlighting why medication reconciliation matters so much, I currently have a case where the patient who went into a facility able to walk and talk is now dying because the facility made a change of the PRN morphine to routine without notifying hospice or the family; and it was caught through medication reconciliation in addition to observation and assessment of the patient who is actively dying because of the medication decisions made by the facility.

Recommended Frequency of Medication Reconciliation

Medication reconciliation should be performed at several points during a patient's hospice care, including:

  • Admission: When a patient is admitted to hospice care, a complete medication history should be obtained and compared to the medication orders.
  • Recertification: When a patient's hospice care is recertified, medication reconciliation should be performed to ensure that the patient's medication regimen is still appropriate.
  • : If a patient's condition changes, medication reconciliation should be performed to ensure that the medication regimen is still appropriate.
  • Medication Changes: If a patient's medication regimen is changed, medication reconciliation should be performed to ensure that the new medications are appropriate and do not interact with other medications the patient is taking.
  • Respite: When a patient is admitted to , medication reconciliation should be performed to ensure that the patient's medication regimen is still appropriate.
  • Revocation: When a patient revokes hospice care, medication reconciliation should be performed to ensure that the patient's medication regimen is still appropriate.
  • Discharge for Cause: When a patient is discharged from hospice care for cause, medication reconciliation should be performed to ensure that the patient's medication regimen is still appropriate.
  • Discharge for Failure to Decline: When a patient is discharged from hospice care for failure to decline, medication reconciliation should be performed to ensure that the patient's medication regimen is still appropriate.

The Medication Reconciliation Process

The medication reconciliation process revolves around maintaining a single list documenting a patient's current medications. This list should be continually updated to reflect changes accurately. Here's a simplified step-by-step process:

  1. Gather Information: Collect details on the patient's current medications, including prescription drugs, over-the-counter products, and supplements.
  2. Verify Information: Confirm the accuracy of the medication list with the patient, their family, and any other healthcare providers involved.
  3. Update the List: Modify the list to reflect any changes, such as medication additions, removals, or dosage adjustments.
  4. Communicate: Share the updated list with the hospice team, ensuring everyone involved is aware of the patient's medication regimen. If the changes were at a facility, communicate the changes with the family.
  5. Regular : Continually reassess and update the medication list to adapt to the patient's evolving needs.

Beers Criteria and STOPP/START Criteria

The Beers Criteria is a list of medications that are potentially inappropriate for use in older adults due to their substantial risk of adverse drug reactions. The STOPP/START criteria is a tool that can be used to identify potentially inappropriate medications and potential prescribing omissions in older adults. Healthcare professionals should be familiar with these criteria and use them to medication reconciliation in hospice care.

What are the Beers Criteria and how are they used in medication reconciliation?

The Beers Criteria is a list of medications that are potentially inappropriate for use in older adults due to their substantial risk of adverse drug reactions. The latest version of the AGS Beers Criteria was written in 2019 to assist practicing clinicians in outpatient, acute, and institutional settings. It includes medications evaluated in five main categories: drugs to avoid, drugs to use with caution, drug-drug interactions, medications to avoid in particular clinical situations, and dosage according to kidney function. The Beers Criteria is a tool used to identify high-risk medications prescribed to older adults with the intent of de-prescribing medications that may lead to adverse drug reactions. By implementing the Beers Criteria into the medication reconciliation process, the primary objective is to increase the number of charts for geriatric patients that have been reviewed for potentially inappropriate medication use. The Beers Criteria serves as standard guidance for clinicians to prevent potentially inappropriate prescribing in patients age 65 years and older

What are some examples of medications that are included in the Beers Criteria?

The Beers Criteria is a list of medications that are potentially inappropriate for use in older adults due to their substantial risk of adverse drug reactions. Here are some examples of medications that are included in the Beers Criteria:

  • Analgesics (meperidine): Neurotoxicity, .
  • Antibiotics (ciprofloxacin with warfarin): Increased risk of bleeding.
  • Anticholinergics (diphenhydramine): Increased risk of confusion, dry mouth, constipation, and other side effects.
  • Antipsychotics (haloperidol): Increased risk of stroke, cognitive impairment, and other side effects.
  • Benzodiazepines (diazepam): Increased risk of falls, cognitive impairment, and other side effects.
  • Nonbenzodiazepine sedative-hypnotics (zolpidem): Increased risk of falls, cognitive impairment, and other side effects.
  • Proton pump inhibitors (omeprazole): Increased risk of Clostridium difficile infection, pneumonia, and other side effects.
  • Tricyclic antidepressants (amitriptyline): Increased risk of falls, cognitive impairment, and other side effects.

It is important to note that the Beers Criteria is not a comprehensive list and that healthcare professionals should use their clinical judgment when prescribing medications to older adults.

What are the STOPP/START criteria and how are they used in medication reconciliation?

The STOPP/START criteria are a tool used to identify potentially inappropriate medications and potential prescribing omissions in older adults. The criteria consist of two parts:

  1. STOPP (Screening Tool of Older Persons' Prescriptions): This tool consists of sixty-five indicators for potentially inappropriate medications (PIM), which commonly cause drug-drug and disease interactions. The STOPP criteria are used to identify medications that should be avoided in older adults due to their substantial risk of adverse drug reactions.
  2. START (Screening Tool to Alert to Right Treatment): This tool consists of twenty-two indicators for potential prescribing omissions, which are medications that should be prescribed to older adults but are not. The START criteria are used to identify medications that should be prescribed to older adults to improve their health outcomes.

The STOPP/START criteria are used as a tool for clinicians to potentially inappropriate medications in older adults and have been endorsed as a best practice by some organizations2. The criteria are used in medication reconciliation to identify medications that may need to be adjusted or discontinued to prevent adverse drug reactions and improve patient outcomes. Several studies have shown that the use of the STOPP/START criteria can improve medication appropriateness in older adults. The criteria have been used to review the medication profiles of community-dwelling, acute care, and long-term care patients. The criteria have also been shown to be effective in preventing polypharmacy in older adults

What are some examples of medications that are included in the STOPP/START criteria?

The STOPP/START criteria are a tool used to identify potentially inappropriate medications and potential prescribing omissions in older adults. Here are some examples of medications that are included in the STOPP/START criteria:

  • Antipsychotics (haloperidol): Increased risk of stroke, cognitive impairment, and other side effects.
  • Benzodiazepines (diazepam): Increased risk of falls, cognitive impairment, and other side effects.
  • Nonbenzodiazepine sedative-hypnotics (zolpidem): Increased risk of falls, cognitive impairment, and other side effects.
  • Proton pump inhibitors (omeprazole): Increased risk of Clostridium difficile infection, pneumonia, and other side effects.
  • Tricyclic antidepressants (amitriptyline): Increased risk of falls, cognitive impairment, and other side effects.
  • Anticholinergics (diphenhydramine): Increased risk of confusion, dry mouth, constipation, and other side effects.
  • NSAIDs (ibuprofen): Increased risk of gastrointestinal bleeding and other side effects.
  • Anticoagulants (warfarin): Increased risk of bleeding.
  • Digoxin: Increased risk of toxicity in older adults with renal impairment.

It is important to note that the STOPP/START criteria are not a comprehensive list and that healthcare professionals should use their clinical judgment when prescribing medications to older adults. They should also consider a person's general health, all underlying medical conditions, or circumstances that may lead a healthcare provider to choose a specific medication.

Key Differences Between the Beers Criteria and the STOPP/START Criteria in Medication Reconciliation

The Beers Criteria and the STOPP/START criteria are both tools used in medication reconciliation to identify potentially inappropriate medications and potential prescribing omissions in older adults. However, there are some key differences between the two tools:

Beers Criteria

  • Developed in the United States
  • Focuses on medications that are potentially inappropriate for use in older adults due to their substantial risk of adverse drug reactions
  • Includes medications evaluated in five main categories: drugs to avoid, drugs to use with caution, drug-drug interactions, medications to avoid in particular clinical situations, and dosage according to kidney function
  • Consists of fifty-three medications or medication classes that should be avoided or used with caution in older adults

STOPP/START Criteria

  • Developed in Europe
  • Focuses on potentially inappropriate medications and potential prescribing omissions in older adults
  • Includes sixty-five indicators for potentially inappropriate medications (STOPP) and twenty-two indicators for potential prescribing omissions (START)
  • Considers the patient's clinical status, comorbidities, and other factors that may affect medication appropriateness

The STOPP/START criteria is considered to be more comprehensive and sensitive to assess potentially inappropriate medications compared to the Beers Criteria. The STOPP/START criteria offer more benefits than the Beers criteria in improving patient outcomes and medication therapy. However, the Beers Criteria is still widely used in the United States and is considered a standard guidance for clinicians to prevent potentially inappropriate prescribing in patients age 65 years and older.

Which criteria are more comprehensive in assessing potentially inappropriate medications (PIMs)?

The STOPP/START criteria is considered to be more comprehensive in assessing potentially inappropriate medications (PIMs) compared to the Beers Criteria. The STOPP/START criteria are more sensitive to assess potentially inappropriate medications and potential prescribing omissions in older adults. The STOPP/START criteria consider the patient's clinical status, comorbidities, and other factors that may affect medication appropriateness. On the other hand, the Beers Criteria focuses on medications that are potentially inappropriate for use in older adults due to their substantial risk of adverse drug reactions. However, it is important to note that neither tool is perfect, and healthcare professionals should use their clinical judgment when prescribing medications to older adults

Is Either Tool the Best Tool for Medication Reconciliation?

Both the Beers Criteria and the STOPP/START criteria are useful tools in medication reconciliation for older adults. However, neither tool is perfect, and healthcare professionals should use their clinical judgment when prescribing medications to older adults. They should also consider a person's general health, all underlying medical conditions, or circumstances that may lead a healthcare provider to choose a specific medication. The choice of which tool to use may depend on the healthcare setting, the patient population, and the healthcare professional's familiarity with the tool.

Common Medications Involved in Causing and Other Medication-Induced Syndromes

Serotonin syndrome is a potentially life-threatening condition that can occur when a patient takes medications that increase serotonin levels in the brain. Some common medications that can cause include:

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
  • Tricyclic antidepressants (TCAs)
  • Monoamine oxidase inhibitors (MAOIs)
  • Opioids
  • Triptans (used to treat migraines)
  • St. John's Wort (a herbal supplement)

Other medication-induced syndromes that can hasten death or increase during the dying process include:

  • Anticholinergic syndrome: This can occur when a patient takes medications that block the action of acetylcholine, a neurotransmitter that is involved in many bodily functions. Symptoms can include confusion, dry mouth, blurred vision, and constipation.
  • Neuroleptic malignant syndrome: This can occur when a patient takes medications that block dopamine receptors in the brain. Symptoms can include fever, muscle rigidity, and altered mental status.
  • Extrapyramidal symptoms: These can occur when a patient takes medications that block dopamine receptors in the brain. Symptoms can include tremors, rigidity, and akathisia (a feeling of ).

Healthcare professionals should be aware of these medication-induced syndromes and take steps to prevent them in hospice patients.

Conclusion

In conclusion, medication reconciliation is a crucial process in hospice care that can help prevent medication errors, reduce the risk of adverse drug reactions, and improve patient outcomes. Healthcare professionals should perform medication reconciliation at several points during a patient's hospice care and be familiar with the Beers Criteria and STOPP/START criteria. They should also be aware of common medications that can cause serotonin syndrome and other medication-induced syndromes that can hasten death or increase during the dying process.

Resources

The Importance of Caregiver Journaling

Reporting Changes of Condition to Hospice

Hospice Medication Reconciliation Clinical Vignettes

Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Medication Reconciliation

The Role of the Nurse in the Management of Medicines During Transitional Care: A Systematic Review

Inappropriate Medication in the Geriatric Population

Understanding the Beers Criteria Is Essential

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

How to Use the AGS 2015 Beers Criteria – A Guide for Patients, Clinicians, Health Systems, and Payors

American Geriatrics Society 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Medication Reconciliation Victory After an Avoidable Error

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

Explicit criteria as clinical tools to minimize inappropriate medication use and its consequences

Designing the Medication Reconciliation Process

Medication Reconciliation | PSNet

Overcoming the pitfalls of medication reconciliation

Eldercare Locator: a nationwide service that connects older Americans and their caregivers with trustworthy local support resources

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My Aging Parent Needs Help!: 7 Step Guide to Caregiving with No Regrets, More Compassion, and Going from Overwhelmed to Organized [Includes Tips for Caregiver Burnout]

Take Back Your Life: A Caregiver's Guide to Finding Freedom in the Midst of Overwhelm

The Conscious Caregiver: A Mindful Approach to Caring for Your Loved One Without Losing Yourself

Dear Caregiver, It's Your Life Too: 71 Self-Care Tips To Manage Stress, Avoid Burnout And Find Joy Again While Caring For A Loved One

Everything Happens for a Reason: And Other Lies I've Loved

The Art of Dying

Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

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