Hospice doctors generally do not actively target root causes of disease in treating patients—we treat symptoms. The patients’ drugs are usually max-ed out anyway and further intervention in the underlying cause of patients’ problems is futile. We usually maintain appropriate medications the patient was taking when admitted to hospice, and tinker with them minimally.
But sometimes an intervention in the patient’s drug regime is so obvious, and easy, that we do intervene. For example, a cardiac patient may be running a blood pressure that is too high for the optimal treatment of heart failure. A simple increase in the dose of an antihypertensive medication may lower the pressure, improve cardiac function, and make the patient more comfortable. Or adding a low dose steroid to a patient with severe emphysema can do wonders for the comfort of a patient.
Another area ripe for active intervention springs from complicated, extensive drug regimens. For me It was almost impossible to resist trying to rationalize startlingly burdensome amounts of prescriptions. Patients routinely came under our care with 20 medications, some of which were actually harmful. This partially reflects the pharmaceutical industry’s other worldly marketing. Patients and families often resist stopping a cholesterol lowering drug, for instance, even though the patient is malnourished and weighs less than 90 pounds. The drug companies have persuaded them that they need to take these medications right to the end of life. Convincing families and patients of the dangers, and futility, of these drugs can be very difficult, however, as the marketing leaves an imprint that can be impervious to reason.
Paring down the medication burden is most rewarding when patients are on a plethora of psychoactive medications. It was not unusual, for instance, to encounter patients new to hospice on multiple drugs that can impair consciousness. The genesis of such insupportable regimens springs from the various sites of care that a patient has encountered before coming to hospice: nursing homes, assisted living facilities, emergency rooms, urgent care centers, and hospitals. Each setting finds a doctor responding to symptoms such as agitation, anxiety, psychosis, and depression by layering on more medications without the careful review of all medications that a good primary care doctor does.
Jean Paul was an 83 year old male with mild to moderate dementia, but, except for some extreme episodes of agitation, which sometimes threatened violence, his wife was able to care for him at home. A conscientious caretaker, she administered all of his medications as directed. These had accumulated from episodes of care in multiple settings and, for each of these encounters, new psychoactive drugs, most of them with sedating side effects, were often prescribed without apparent attention to the patient’s entire drug regimen.
Over the course of a few months, Jean Paul’s wife began to notice a decline in his alertness, and this soon progressed to stuporousness. It seemed his dementia was precipitously worsening and that it was time for hospice.
In her initial evaluation, his hospice nurse found that Jean Paul was on two antipsychotics, two anti-anxiety pills and two sleeping pills–conscientiously administered by his wife as scheduled. We slowly tapered all of these drugs, and the patient’s alertness improved weekly. Finally, after three months, the patient reverted to his level of mental acuity from about four months prior. Caring for him was still a challenge, but he was no longer appropriate for hospice care. The hospice team helped to line up agencies to assist his wife with his care, and we discharged him with the promise that he could always be readmitted to hospice care if clinical deterioration warranted it.