Withdrawing Treatment and Deprescribing
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Withdrawing Treatment and Deprescribing

Key Messages

  • Decisions regarding withdrawing of treatment are ideally made in conjunction with the person, the family and members of the care team. [1,2]
  • Sensitive discussion should precede any deprescribing as the discontinuation of a long-standing medication may cause distress to both the person and close relatives. [2,3]
  • When a person’s condition deteriorates in the last days to weeks of life, medications that are unnecessary for symptom relief or comfort would usually be withdrawn. [4]
  • There is evidence that deprescribing improves medication appropriateness but there is little evidence that it improves health outcomes or quality of life in older people. [5-7]
  • STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy) is a tool that can assist with the deprescribing of medications in frail older patients with limited life expectancy. [8,9]

Background

Cessation of non-essential or inappropriate medications (deprescribing) is not the same as withdrawal of treatment or the decision not to initiate curative or potentially life-prolonging treatments. [6] Deprescribing is the systematic process of identifying and discontinuing drugs (treatments) in instances in which existing or potential harms outweigh existing or potential benefits within the context of an individual’s care goals, current level of functioning, life expectancy, values, and preferences. [2,6,7,10,11]

Any withdrawal of medication or life-sustaining therapy is best done in conjunction with the person and the goals of care with consideration of symptom management and family support. [2,10,12]

Evidence Summary

Withdrawal of treatment

Currently, there are no guidelines for the withdrawal of treatment. Most evidence is regarding Intensive Care Unit (ICU) decision-making around withdrawal of ventilation and in people who have a critical illness involving the brain, spinal cord or nerves e.g. stroke, brain injuries and brain death. [12,13]

In the absence of guidelines, the decision to withdraw treatment includes consultation between health professionals, the individual and family. [1,2,4] Each situation is managed individually and once decisions are made to withdraw treatment, emotional support is an important part of the process for both the person and the family/carers. [2,4] Discussions of what might happen after withdrawal, including clear descriptions of withdrawal symptoms, need to be discussed. [4]

Deprescribing

Deprescribing aims to reduce polypharmacy (multiple, potentially inappropriate medications) and improve patient outcomes. [2,5-9,11,14] Deprescribing considers whether the existing or potential harms outweigh existing or potential benefits within the context of the person’s care goals, current level of functioning, life-expectancy, values, and preferences. Using a structured process, a clinician plans and supervises the identification and tapering or stopping of medications. [2,6,7,9] There is evidence that deprescribing improves medication appropriateness but there little evidence that it improves health outcomes [5,7] or quality of life [6,7] in older people. Deprescribing of inappropriate medications in older patients with life-limiting illness and limited life expectancy is complex and challenging. [7]

One important barrier to deprescribing is the limited time available for GPs and other healthcare professionals to discuss goals of care and to closely monitor patients after treatment discontinuation. [9]

STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy) provides a list of indicators of potentially inappropriate prescribing that has been designed to assist physicians with stopping such medications in older patients (≥65 years) who meet established criteria. [8] This tool has shown consistent results across GPs, geriatricians and palliative care physicians caring for frail older people and those with limited life expectancy. [14]

There were no articles within this search regarding the withholding of nutrition/fluids which indicate a gap in current research.

Quality Statement

Most of the systematic reviews were adequate with two that were high quality. [1,13] In the absence of guidelines, clear and simple communication and psychosocial support before any decisions are made regarding withdrawal of treatment or medications are key points in all the review discussions.
 

Page updated 27 August 2021

  • References

  • About PubMed Search

  1. Clarke G, Johnston S, Corrie P, Kuhn I, Barclay S. Withdrawal of anticancer therapy in advanced disease: a systematic literature review. BMC Cancer. 2015 Nov 11;15:892.
  2. The Royal Australian College of General Practitioners (RACGP). RACGP aged care clinical guide (Silver Book) [Internet]. Melbourne (AU): RACGP; 2019. [cited 2021 Jun 9].
  3. Lindsay J, Dooley M, Martin J, Fay M, Kearney A, Khatun M, et al. The development and evaluation of an oncological palliative care deprescribing guideline: the 'OncPal deprescribing guideline'. Support Care Cancer. 2015 Jan;23(1):71-8.
  4. Therapeutic Guidelines Limited. Therapeutic Guidelines: Palliative Care. Version 4. Melbourne: Therapeutic Guidelines Ltd, 2016.
  5. Anderson LJ, Schnipper JL, Nuckols TK, Shane R, Sarkisian C, Le MM, et al. A systematic overview of systematic reviews evaluating interventions addressing polypharmacy. Am J Health Syst Pharm. 2019 Oct 15;76(21):1777-1787. doi: 10.1093/ajhp/zxz196.
  6. Pruskowski JA, Springer S, Thorpe CT, Klein-Fedyshin M, Handler SM. Does Deprescribing Improve Quality of Life? A Systematic Review of the Literature. Drugs Aging. 2019 Dec;36(12):1097-1110. doi: 10.1007/s40266-019-00717-1.
  7. Shrestha S, Poudel A, Steadman K, Nissen L. Outcomes of deprescribing interventions in older patients with life-limiting illness and limited life expectancy: A systematic review. Br J Clin Pharmacol. 2020 Oct;86(10):1931-1945. doi: 10.1111/bcp.14113. Epub 2019 Dec 12.
  8. Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing. 2017 Jan 23.
  9. Paque K, Vander Stichele R, Elseviers M, Pardon K, Dilles T, Deliens L, et al. Barriers and enablers to deprescribing in people with a life-limiting disease: A systematic review. Palliat Med. 2019 Jan;33(1):37-48. doi: 10.1177/0269216318801124. Epub 2018 Sep 19.
  10. Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015 May;175(5):827-34.
  11. Lundby C, Graabaek T, Ryg J, Søndergaard J, Pottegård A, Nielsen DS. Health care professionals' attitudes towards deprescribing in older patients with limited life expectancy: A systematic review. Br J Clin Pharmacol. 2019 May;85(5):868-892. doi: 10.1111/bcp.13861. Epub 2019 Feb 27.
  12. Frontera JA, Curtis JR, Nelson JE, Campbell M, Gabriel M, Mosenthal AC, et al. Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2015 Sep;43(9):1964-77.
  13. Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med. 2015 Sep;41(9):1572-85.
  14. Thompson W, Lundby C, Graabaek T, Nielsen DS, Ryg J, Søndergaard J, et al. Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review. J Am Geriatr Soc. 2019 Jan;67(1):172-180. doi: 10.1111/jgs.15616. Epub 2018 Oct 13.


Definition

Withholding Treatment

Withholding or withdrawal of a particular treatment or treatments, often (but not necessarily) life-prolonging treatment, from a patient or from a research subject as part of a research protocol. The concept is differentiated from REFUSAL TO TREAT, where the emphasis is on the health professional's or health facility's refusal to treat a patient or group of patients when the patient or the patient's representative requests treatment. Withholding of life-prolonging treatment is usually indexed only with EUTHANASIA, PASSIVE, unless the distinction between withholding and withdrawing treatment, or the issue of withholding palliative rather than curative treatment, is discussed. (MESH)

'Euthanasia and assisted suicide are different from withholding or withdrawing life-sustaining treatment in accordance with good medical practice by a medical practitioner. When treatment is withheld or withdrawn in these circumstances, and a patient subsequently dies, the law classifies the cause of death as the patient’s underlying condition and not the actions of others'. [1]

Decision making at the end of life can often involve very difficult and emotional decisions about whether to start or stop a treatment. For example, whether or not to start mechanical ventilation or whether to stop PEG feeding. These decisions need to consider whether something is burdensome for the patient – in other words, quality of life. (Caresearch https://www.caresearch.com.au/caresearch/tabid/1547/Default.aspx)

Search String

(((stop[ti] OR stopping[ti] OR cease[ti] OR cessation[ti] OR ceasing[ti] OR withdraw*[ti] OR discontinu*[ti] OR halt*[ti] OR withhold*[ti] OR refus*[ti] OR forego[ti] OR foregoing [ti] OR use[ti]) AND (treatment[ti] OR therapy[ti] OR hydration[ti] OR nutrition[ti] OR feeding[ti] OR ventilation[ti] OR medication*[ti])) OR "Withholding Treatment"[Mesh] OR "Deprescriptions"[Mesh] OR deprescri*[tiab] OR de prescri*[tiab])