What meds to keep

[laderalis]

How do you (with the Dr of course, if applicable) decide what meds to keep and what meds to discontinue? I have two patients on hospice who are still on thyroid pills. Is this common? They are both doing pretty good and death is not imminent for either. They actually have improved while on hospice.

I also have a patient who is a brittle diabetic on hospice. She had been on AC & HS gluco checks, with sliding scale coverage. The sliding scale was completely discontinued. She began to have some hyperglycemia at HS about a week later. She was then put on just a before dinner check with sliding scale coverage and has been doing well with that. She still gets her long acting insulin. Is this normal? We were happy not to poke her finger 4 times a day, but worried about hyperglycemia. She still gets checked twice a week and has had no further problems.

[NC29mom, ASN, LPN, RN]

Do you have a hospice pharmacy you can consult with for recommendations?

We generally get rid of namenda\aricept for our dementia pts (amazing how long drs keep pts on these), supplements. I generally dont adjust dm regimens unless pt not eating. Can the family not be taught how to perform fsbs?

Your best bet is to confer with your pharmacist, then dr, then family regarding which meds aren't covered. ..then decide. In my experience, families arent very open to stopping a lot of meds...dependant upon the pts condition of course.

[s0ad]

I have had hospice patients on no medications, and hospice patients on up to 10 medications or so. The key, I've noticed, is comfort. While having fingers poked may not be comfortable, neither are hyperglycemic/hypoglycemic events. And while taking a thyroid pill may be a minor annoyance, having the side effects of an uncontrolled thyroid can produce uncomfortable symptoms. I've had patients on BP medications, inhalers, etc. Usually the vitamins are eliminated (depending on the patient's ability to comfortably swallow medications), but I've found everything else just depends.

[tewdles, RN]

No need to stop routine meds when the patients are doing well. Don't cause problems they don't need.

Most of those drugs will be covered by insurance.

When the diabetic becomes anorexic you can DC the insulin.

Good questions.

[CJ9330]

I find it's a case by case decision. I seldom d/c things like BP or thyroid meds, inhalers, etc., especially if they are still doing well; but as a decline starts, I frequently try to get a sense of how the family feels about discontinuing anything 'unnecessary', i.e. vitamins, appetite stimulants, etc. As suggested above, I also frequently call our hospice pharmacist and/or MD for suggestions.

[tnguy31]

Thank you for posting this topic. I found it so helpful.

[ashcarr30]

I thought this was a great topic and I wish there was more information out there. I have pt's come onto our program with multiple BP meds, cholesterol meds, thyroid meds, multiple BPH meds, psych meds.... the question is not just what meds to we keep but when to we start to taper longstanding meds (such as psych meds) so we can avoid an abrupt d/c of these meds when they stop swallowing which is also not ideal.

I have recently started to slowly remove BP meds in homes where pts have ability to monitor BP daily. I am amazed how well most of them do without their BP meds. In fact, in all the homes I have d/ced their BP meds (only been working with hospice for last 9 months and getting more and more intersted in polypharmacy at end of life in past 4 mo) I have never once had to restart. With most geriatric practioners I speak with they typically say that having a pt with a slightly elevated BP is a better situation than a low BP as it increases their risk for falls.

I would be interested to stop thyroid meds and then after a few weeks check their labs and see if there are any issues. Looking up the impact of inappropriate dosage of levothyroxine, side effects and drug interactions, it does seem like something that would be worthwhile to discontinue if possible.

I am hoping to go to NP school in the spring and would love to further study polypharmacy at end-of-life and when to dc meds.

[curiousauntie]

I would say to look at the pt, look at the med...what will happen if they stop the med? I take thyroid medication. If my TSH is just slightly elevated, I feel like CRAP. I tell family members that the thyroid med should be one of the last meds stopped. (as a side note, I had a pt who had been on another hospice and asked me to have a thyroid panel done on admission to us, as the other hospice insisted she had to stop her Synthroid. Her TSH was one of the highest I have ever seen in many years of nursing...no wonder she slept 16 hours a night and napped during the day, had gained 20 lbs, was losing her hair and had "bug" eyes!) I usually sugg stopping vitamins, appetite stimulants (if the family and pt are ready for that) and try to get the doc to pare down the number of BP meds (because as stated above, a slightly high BP is sooo much better than a low one). Psych meds? I try not to touch them too much. Most hospice pts can use a bit of an antidepressant and anyone on an antipsychotic probably really needs it :) BPH meds? I really would rather have them peeing as opposed to needing a chronic foley.

So many older people are on way too many meds and could probably stand to have them cut in half, and that is the general public, not hospice pts. After the medical journey most hospice pts take to get to hospice (multiple docs, hospital admissions, ER visits...) they usually have 3 pills to treat something and 2 to treat the side effects (Nexium, anyone?) I do a lot of admissions as an on-call nurse and get so tired of writing 3 pages of medications, and try to suggest to the MD that maybe we could d/c some of these redundant medications. Sometimes they are in agreement, sometimes they want to wait a bit. But at least I have opened the line of communication with the pt, family and doc to start the process.