Additional Material


Futile Medicines in Hospice

Futile meds in hospice:

  • Percent mortality = age + burn %
  • withholding futile meds or medical care does speed nor encourage the onset of death.
  • Hippocratic oath : “under no circumstances will we prescribe a deadly drug nor give give advice which may cause death”.
  • Futile meds: no further benefits using the meds, but may prolong death / dying process, desired outcome can not be met, anything < 5 % chances of success would be futile, poor quality of life to continue the treatment, no useful purpose

1. Aspirin : risk is more than benefit,

2.Docusate (Colace): Lack of proven efficacy / risks / benefits. Side effects of it. Solution taste very bad for 2-3 hrs

3. Meds for Alzheimer’s: are not effective in terminal patients.

4. Statins: No good evidence that statins being effective in terminal patients. PROVE IT (study)– excluded patients who were likely to die within 2 years. No evidence that stopping statins in patients with chronic cardiac disease increases mortality except higher LDLs. Side effects: Myopathy, drug-drug interactions,

5. Multi-Vitamins: are not proven to be effective. Side effects: unpleasant taste, indigestion, constipation, nausea, expense.

6. Beer’s criteria : archives of internal medicine: futile meds in nursing home population: 13 specialist, 30 criterias: sedative-hypnotics, antidepressants, antipsychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, H2 blockers, antibiotics, decongestants, iron supplements, muscle relaxants, GI antispasmodics, and antiemetics.

7. Doctors are able to do reduce unneccesory meds by 7.3 to 7.5%

8. NEW ORLEANS – Futile / duplicate medications remain a largest burden among patients at the end of life, according to a blinded, prospective cohort study of 397 consecutive hospice patients. At some point in their end of life care, 39% of patients received futile medications such as statins, and 19% received duplicate medications.

9. Vitamins and minerals including calcium, iron, and fish oil supplements made up the bulk of futile medications (67%), followed by statins (21%), and other medications (12%) including allopurinol (Zyloprim and generics), Imodium, megestrol acetate (Megace), Metamucil, epoetin alfa (Epogen), alendronate sodium (Fosamax), cholestyramine (Questran), and silodosin (Rapaflo), Mr. Munshi reported.

10. Questionable medications were anticoagulants/antiplatelets (36%), Alzheimer’s medications (18%), electrolytes (14%), appetite stimulants (9%), and other (23%) including acetaminophen, ranitidine (Zantac), methylphenidate (Ritalin), amphetamine and dextroamphetamine (Adderall), cetirizine (Zyrtec), Sudafed, etc.

11. Ventilator : can be discontinue

12. CPR: not needed

13. Food, fluids can be stopped.

14. About 51 articles examined in detail, three studies relating to cancer have been evaluated. In these retrospective and cross-sectional studies, the incidence of PIMs (potentially inappropriate meds) was shown in approximately 20 % of patients, although the studies were inconsistent.

15. Assess the patient with emphasis on GOALS OF CARE. Balance with perspective from everybody involved including primary care, oncologist and other colleague on your team.

16. If you come across some meds you believe are futile, then do not hesitate to drop us a note.

Thanks

Kazmi, MD

 



 

SYMPTOM CLUSTERS: 3 or more coexisting symptoms related to one & another occuring concurrently having synergistic effect on outcome.

  • adaptive responses preserve energy.
  • MALADAPTIVE RESPONSE : happens in chronic illnesses leading to multiple symptoms eg. anorexia (80%), depression, fatigue (90%) malaise, pain (80%), confusion (80%), nausea (90%), SOB (50%),
  • Fatigue: causes: meds, anorexia, poor nutrition, anemia, pain, depression, anemia,
    • Rx: ESA (Erythropoitin stimulating hormone) : no help;
    • Psychostimulants :
      • Methylphenidate (Ritalin): 5-30 mg bid last dose before 4 pm;
        • helps: with appetite, depression, pain, anxiety,
      • Modafanil (Provigil) 50-400 mg qam; some improvement
    • Steroids : Pulse therapy 4-16 mg /d then 1-2 mgt /d divided dosage last dose before 2 pm