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. [2,6,9,10]
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. [2,9,11]
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. [11,12]
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. [2,5-8,10,13] 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. [2,6,8] There is evidence that deprescribing improves medication appropriateness but there little evidence that it improves health outcomes [5] or quality of life [6] in older people.
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. [8]
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. [7] This tool has shown consistent results across GPs, geriatricians and palliative care physicians caring for frail older people and those with limited life expectancy. [13]
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. [1,12] 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 09 June 2021