She counts them out every Sunday evening. Seven in the morning slot. Four at noon. Five before bed. Her husband watches from the kitchen doorway, arms crossed, quiet. He stopped asking what each one does about three years ago. The pharmacist keeps refilling them. The doctor reviews the chart for maybe ten minutes twice a year. Nobody sits down and asks: Does any of this still make sense?
That question matters. A lot.
The Pill Bottle Nobody Questions
How the Prescribing Cascade Begins
Here is how it often goes. A blood pressure medication causes dizziness. The dizziness leads to a fall. The fall leads to a bone-protecting drug. That drug irritates the stomach lining, so an antacid is added. Now there are four medications where there used to be one, and nobody has stepped back to ask whether the original prescription still fits, whether the dose is still appropriate, or whether the person’s kidneys can even process it the same way they could fifteen years ago.
This is called a prescribing cascade. Far more common than most families realize.
Deprescribing — the careful, structured process of reviewing medications and removing the ones that are no longer helping, or are actively causing harm — is rarely initiated by providers, even when someone is seriously ill or nearing the end of life. A thorough medication reconciliation might take 45 minutes. A standard appointment is 15. Providers worry about liability. They worry about stepping on another specialist’s decisions. The system simply does not reward the time a genuine review requires.
The person in the bed pays the price.
Side Effects Don’t Come with an Expiration Date
The Longer the Prescription, the Higher the Risk
Every medication carries risk. That risk grows the longer someone takes it.
Not immediately. Not always visibly. But it accumulates — quietly, over months and years — until the damage surfaces in ways that get blamed on aging or on the illness itself.
Margaret was prescribed a statin for high cholesterol at 57. She tolerated it without obvious problems for years. By 74, living with a serious cardiac condition, everything had changed. She was waking up every morning with muscle pain so severe that she could not pull herself out of bed. Walking to the bathroom took concentrated effort. Her legs felt heavy, weak, and burning. She developed confusion — forgetting where she put things, losing words mid-sentence, and being unable to follow a conversation the way she once could. Then came the multiple diagnoses: Alzheimer’s Disease and type II diabetes to start.
Three devastating conditions. One drug.
The FDA issued a formal label warning on statins in 2012, acknowledging that statins cause documented cognitive effects — including memory loss and confusion serious enough to be mistaken for dementia — along with a measurably increased risk of developing Type 2 diabetes. Published case reports document patients who developed progressive cognitive decline and dementia-like presentations after starting statin therapy, with symptoms reversing when the medication was stopped. Research published in peer-reviewed journals confirms statins impair insulin sensitivity and directly contribute to the development of new-onset diabetes, with some high-intensity statins driving that risk even higher.
And the muscle damage. Statin-induced myopathy is well-documented, from mild aching all the way to rhabdomyolysis, a severe breakdown of muscle cells that has left patients entirely unable to walk, and that can progress to kidney failure. In published case reports, patients lost the ability to ambulate independently because of a single medication that had been quietly destroying their muscles for years.
Margaret’s doctor called it aging. Nobody connected the dots.
Adults taking ten or more medications face a near-certain risk of adverse drug reactions, and that risk compounds with every passing year and every organ change that comes with serious illness. Side effects are not a question of “if.” They are a matter of time.
Who Is Your Doctor Really Working For?
Insurance, Pharmacy Ownership, and the Profit Chain
Picture a Tuesday morning in a busy clinic. An 82-year-old sits in the exam room with 11 medications on her list, written by five different specialists. The provider types notes organized around billing codes, each one structured to satisfy what insurance will reimburse. The medication review that could take 45 careful minutes never happens — not because the doctor doesn’t care, but because the system does not make it financially possible.
Insurance companies maintain formularies — approved drug lists built around negotiated contracts with manufacturers, not always around what is best for the individual in the room. Some of the largest insurance companies in the country also own pharmacy benefit managers and, in some cases, pharmacies outright, which means the same company that decides which drugs your doctor can prescribe also profits when those prescriptions are filled.
One in five prescriptions written for older adults has been identified as clinically inappropriate. That is not a fringe statistic. That is a structural reality built into the system that most families trust completely.
Understanding how that structure works helps families ask better questions — and recognize when the answers don’t add up.
What a Medication Review Actually Does
Palliative Care, Hospice, and Health Navigators
Picture a different kind of appointment. A palliative care nurse sits at a kitchen table with a family. She has the medication list spread out in front of her — 14 drugs, across six different prescribers, filled at two different pharmacies. For each one, she asks, “What is this for?” Is it still working? Could it be behind the confusion, the fatigue, the muscle pain, the new diabetes diagnosis we have been attributing to something else? Does staying on this drug align with what this person says they want for their life right now?
That conversation changes things.
Palliative care teams, hospice nurses, and health and life navigation specialists are trained to do exactly this work. Structured tools guide the process — the BEERS Criteria, which identifies medications frequently inappropriate for older adults, and the STOPP/START criteria, which help clinicians identify what to stop and what may actually be missing from the regimen. These are evidence-based frameworks built specifically for this population.
Medications are tapered carefully and monitored, with the person’s comfort and goals at the center of every step.
Families can ask for this. It is a legitimate, recognized part of serious illness care.
What the Research Shows
A 2026 Systematic Review on Deprescribing Outcomes
A systematic review published in Palliative Medicine in early 2026 analyzed data from more than 40 studies involving people in hospice, palliative care, oncology, and advanced chronic disease settings. The findings held steady across a wide range of patients:
Every study measuring medication burden found that deprescribing reduced the total number of drugs or held it steady — none found it made things worse
In the majority of studies tracking mortality, deprescribing had no negative impact on survival
Quality of life, functional status, and mood were largely unchanged, meaning the process did not cause widespread clinical harm
In several studies, healthcare costs went down for patients and families
A small number of patients in select studies did show increased risk, which is precisely why careful monitoring, individualized planning, and honest goals-of-care conversations matter at every step. Deprescribing is not withdrawal. Not giving up on someone. It is a deliberate, active clinical decision, with the person’s values, prognosis, and quality of life at the center of every choice.
Questions Worth Asking at Every Appointment
Families carry more power in this system than they are often led to believe. Showing up to an appointment with a short list of questions — and expecting real answers — is not being difficult. It is being a necessary advocate.
These are the questions worth asking out loud:
Are you prescribing this because it is the best option for my loved one, or because it fits the insurance formulary?
What is the absolute risk reduction percentage for this medication — the real benefit number, not a relative marketing statistic?
What are the known side effects, including cognitive changes, blood sugar effects, and muscle damage, and how does that risk grow over months and years of continued use?
Did you consider non-medication approaches first — nutrition, movement, sleep, lifestyle changes?
Would you be willing to document the benefits and risks we discussed today?
A provider who welcomes these questions is worth staying with. A provider who dismisses them is telling the family something important about how that provider views the relationship.
If your loved one is living with a serious illness, requesting a full medication review is reasonable, supported by research, and long overdue in most cases. Palliative care teams, hospice providers, and health and life navigation specialists can guide that process with skill and genuine compassion. The research backs it. Your loved one deserves it.
Free Daily Symptom Tracker: Each headache, flare, or fatigue spike reveals a clue. This two-page Daily Symptom Tracker records sleep quality, food intake, triggers, severity, and effective relief methods—all in one place. Use it daily for 31 days and share the pages with your healthcare provider or health navigation expert. Together, you can move from guessing to addressing the root cause. Instructions on how to use the free daily symptom tracker and the free daily symptom tracker.
This site uses Amazon Associate links, which means I earn a small commission when you purchase books or products through these links—at no extra cost to you. These earnings help me keep this website running and ad-free, so I can continue providing helpful articles and resources at no charge.
If you don’t see anything you need today but still want to support this work, you can buy me a cup of coffee or tea. Every bit of support helps me continue writing and sharing resources for families during difficult times.
Compassion Crossing Academy — Free and paid online courses are available to teach caregivers, nurses, social workers, chaplains, end-of-life advocates, and educators, including death doulas, how to confidently coordinate complex care.
The Death Deck is often a wonderful conversation starter.
Compassion Crossing, LLC, via Peter M. Abraham, BSN, RN, EOLD, offers on-site services in Madison County, KY, as well as in the seven nearby counties—Clark, Estill, Fayette, Garrard, Jackson, Jessamine, and Rockcastle—and provides virtual options when no local provider is available.
Hospice Buddy: Although Jamie Haberman, RN, CHPN, isn’t a certified end-of-life doula, her virtual services are highly valuable.
Currently, no official organization regulates end-of-life doulas (EOLDs). Remember that some EOLDs listed in directories may no longer be practicing, so it’s important to verify their current status.
End-of-Life Doula Schools
Before you consider a death doula school, please volunteer with a local hospice provider as a “companion volunteer” to gain experience with strangers who are dying, as well as with family and staff dynamics. The author also recommends reading the article Economic rant: The death doula crisis we aren’t talking enough about, as most death doula schools do not emphasize that being a death doula is a calling rather than a career.
The following are end-of-life (aka death doula) schools for those interested in becoming an end-of-life doula:
Compassion Crossing Academy: Although it isn’t a dedicated death-doula school, it offers unique classes that can help death doulas expand their practice. It serves as an important resource for individuals looking to deepen their understanding and grow in this meaningful profession.
Remember that there is no official accrediting body for end-of-life doula programs. Certification simply shows you’ve completed an unaccredited course and received a certificate of completion. It’s advisable to have discovery sessions with any death doula school you’re considering — even if it isn’t listed here — to see if it meets your needs. Also, ask questions and reach out to references, such as former students, to assess whether the school provided a solid foundation for launching your own death doula practice.
