Expert: Deprescribing Is an Important Part of End-of-Life Care

Deprescribing is not a new thing for pharmacy, according to Manju T. Beier, PharmD, BCGP, FASCP, during a session at the American Society of Consultant Pharmacists (ASCP) 2022 Annual Meeting. Deprescribing has been a valuable tool that works in tandem with decisions around the appropriate use of medications when patients are at the end-of-life stage, Beier explained.

In 2018, Beier founded ASCP’s Deprescribing Task Force, and then shortly thereafter, ASCP joined the Choosing Wisely initiative and established a list of statements to help guide discussions with physicians and patients. Choosing Wisely as an organization is focused on promoting conversations between clinicians and patients by helping choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.

“That’s where the rubber meets the road—what is truly necessary, even from a medication standpoint. Remember the old initiative of ‘less is more,’ which was talked about in editorials and things written in archives or international journals,” Beier said. “That’s where the deprescribing comes in for medications for our older patients specifically, who are so vulnerable to pharmacodynamic and pharmacokinetic changes.”

The statements established by ASCP as part of its Choosing Wisely collaboration are a significant accomplishment for ASCP, Beier noted. Yet, the statements remain guidelines for discussions and should not be used to establish coverage decisions or exclusions, as they are meant only to spur conversations.

“It’s not a cookie cutter approach. The clinician thinks about it, the health care practitioner thinks about it, and then you discuss it with the patient—and that’s called shared decision making,” Beier said. “We actually developed a resource and an infographic for SDM—shared decision making—and that’s on the website as well.”

Beier noted that in particular, many of the Choosing Wisely statements established by ASCP focus on drug-drug interactions (DDI) in particular. This focus is important for ASCP due to the specific needs of older adults who have an increased sensitivity to DDI, Beier explained.

The first 5 Choosing Wisely statements were published by ASCP in May 2021, and the second 5 statements followed in June 2022, Beier noted.

“We have a statement for limited life expectancy, and we talked a little bit about palliative and end of life care—there's several papers talking about medications of questionable benefit towards end of life. So we wanted to address that, as well to have meaningful conversations at that point with a less is more approach,” Beier said.

Beier noted that when writing these statements, it was tricky for the authors to write them as they had to begin with “do not use,” “don't recommend,” “don't prescribe,” or “avoid.”

“We normally don't think that way, with a negative starting the sentence,” Beier said. “So that was really a challenge as well, in terms of the composition of things.”

The Choosing Wisely executives then sent the statements written by ASCP to reviewers, which included both physicians and pharmacists. ASCP then had the latitude to either accept or not take the recommendation and then choose to modify the statement appropriately.

Beier explained that some of the areas addressed in the peer reviewed and published ASCP statements as a part of the Choosing Wisely initiative include issues pertaining to calcium channel blockers, comprehensive medication review, medication reconciliation transitions of care, and limited life expectancy. For the latter, Beier noted that to begin to discuss the topic, it is necessary to first provide a definition of what qualifies as a “limited” life expectancy. In their statements, ASCP established limited life expectancy as being 24 months.

Beier noted that 24 months was a number that they decided allowed for conversations with hospice care and palliative care and across various conditions that support the person at that threshold in life.

“Pharmacists need to be a part of that important conversation as well, because a lot of the prescribing happening in the last 24 months of life when the patient is under palliative care or hospice care—many of the drugs of questionable benefit could be taken away,” Beier said.

Beier noted that the concept of time to benefit (TTB) is valuable for these discussions. Beier explained further that TTB is the point in time when patients are expected to derive benefit from a treatment; TTB is primarily used for preventative treatment and not for symptomatic treatment, according to Beier.

“If you have less than 2 years to live, 1 year to live, or 6 months to live—we see many of our older patients, whether it's heart failure or a hip fracture, certainly cancer patients, dementia patients—they could be on statins and polymerase inhibitors all the way to the end,” Beier said. “Many studies have come out and said we should really take a good look at these things.”

Beier explained this concept of TTB is really one to consider pertaining to preventative medications alongside the patient's goals and preferences as well.

“So this is not done in a compartmentalized model willy nilly, let's do it this way, because the family is not going to appreciate that—you have to have conversations and the pharmacist can be very engaging in that perspective,” Beier said.

Reference

Beier MJ. Medication Selection in the Spotlight: ASCP Choosing Wisely Statements Shed Needed Light. Presented at: American Society of Consultant Pharmacists (ASCP) 2022 Annual Meeting in San Antonio, TX; November 5, 2022.