Medications for Comorbidities in Hospice and Palliative Care—Survey of Current Practice Using Statins as a Test Case (310-C)

Abstract

1.Discuss US-based palliative care and hospice clinicians' practices and attitudes regarding the use or discontinuation of medications for comorbidities in the setting of advanced life-limiting illness, and more specifically, use or discontinuation of HMG-coA reductase inhibitor lipid lowering agents (aka "statins") in this setting.2.Discuss the need for more robust evidence to inform decision making in palliative care, with medication continuation/discontinuation as a use case. Discuss the role that hospice and palliative care providers can play in helping to define the clinical research questions that can be answered in clinical trials, such as those conducted by the Palliative Care Cooperative Group. Statins are commonplace in hospice/palliative care but the risks versus benefits of continuing these medications are uncertain. To describe US hospice/palliative care clinicians’ current practices when continuing/discontinuing medications for comorbidities, including statins. Web-based survey and semi-structured interviews. Survey respondents (N = 438) were predominantly physicians (93%), in hospice (23%), palliative care (28%), or combined practice (43%). Fifty-two percent reported certain medications are routinely discontinued upon referral to hospice or palliative care with additional medications subsequently discontinued according to clinical judgment. Twenty percent usually continue patients on medications until risks outweigh benefits. A substantial number (11%) do not routinely stop any medications but decide after discussing risks/benefits with the patient. For primary prevention of cardiovascular events, 43% discontinue statins when life expectancy is limited (mean 24.5 weeks; standard deviation [SD] 23.5 weeks); 37% discontinue based on clinical judgment. When prescribed for secondary prevention, 40% discontinue statins when life expectancy is more limited (mean 19 weeks; SD 17.2 weeks); 21% use clinical judgment. Perceived benefits of statin discontinuation included reduced polypharmacy (96%), side effects (82%), costs to patient (80%), and overall health costs (78%). Perceived harms included increased risk of cardiovascular events (40%) and psychological harm (36%); 42% expected no harm. All interviewees (N = 21) supported discontinuing certain medications in this population. Hospice clinicians commonly recommend discontinuing statins, multivitamins, bisphosphonates, calcium supplements, and cholinesterase inhibitors. In contrast, palliative care clinicians commonly recommend discontinuing antihypertensives, antibiotics, hypoglycemics and insulin. Clinicians who engage in in-depth discussion encounter less resistance from patients/families. Wide practice variation exists regarding management of statins and other medications in the hospice/palliative care population.