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Withdrawing Treatment and Deprescribing - Synthesis

Introduction

The withdrawal of active treatment, including deprescribing of long-term chronic disease medications, is a very difficult topic as there are few guidelines to support decision-making. The evidence often includes the discussion of the four ethical principles used in medical decision making: beneficence, non-maleficence, respect for patient autonomy and justice. [1]

The use of advance care directives in Australia is a starting point for understanding the person’s wishes and preferences at end of life and who they have nominated as their substitute decision maker. In the absence of advance care directives, consultative discussions amongst the health professionals, the person and their close relatives is the starting point. Whenever possible, withdrawal of treatment discussions should be part of the discussion process at the initiation of treatment, so there is clarity about what may need to occur if the treatment is no longer effective.

Polypharmacy, defined as five or more medications, is common in both palliative and aged care settings. [2] As a person enters end-of-life care, the deprescribing of medications that no longer provide benefit, that cause adverse effects or are burdensome to the person, needs to be considered following conversations with the person and family.

Quality Statement 

This synthesis utilised evidence from twelve systematic reviews. Three dealt specifically with topics relating to palliative care in aged care while the rest were palliative care only. The overall quality of the systematic review evidence was good with approach searches and methods for extraction and analysis. No meta-analyses were completed.

In addition, two articles regarding deprescribing guidelines were reviewed and are discussed within the subtitles below.

Research Themes

Life Sustaining Treatment Withdrawal

As there are no evidence-based guidelines for the withdrawal of treatment, it is useful to refer to the goals of palliative care: to relieve a person’s symptoms and suffering, not to intentionally hasten or postpone death. [3] In one Canadian article by van Beinum et al., [4] it was recommended in the ICU setting that all health professionals involved with a person, meet to discuss the person’s progress so that when discussions begin regarding the withdrawal of treatment, all health professionals are giving the same message to the person and the family.  Ideally, involvement of palliative care specialists should be considered sooner rather than later as they provide additional support to the family/carer.

Withdrawal of life supporting treatment, e.g. ventilators or dialysis, often generate strong emotional responses from families. In an American article by Melhado et al., [5] substitute decision-makers who were kept informed on the progress of their relative with open and clear communication with the health professionals found it easier to support the withdrawal process.  And in older patients, futility of treatment was often the reason for withdrawing treatment.

When dealing with neurocritical (life-threatening diseases of the nervous system - the brain, spinal cord and nerves issues), the involvement of palliative care staff is most effective when engaged early so as to build a trusting relationship with the person and their family. [6]

There were no specific systematic reviews or articles regarding the withdrawal of nutrition and hydration. However, Therapeutics Guidelines: Palliative Care version 4, makes it very clear that from an ethical and legal perspective, medically-assisted nutrition and hydration are considered medical treatments. [3] Therefore, there is no requirement for these to be administered to a person who is dying unless they provide relief of symptoms. Health professionals may need to support family/carers in this process due to cultural, emotional and social factors as many families find it distressing to withhold or withdraw such treatment.

Withdrawal of cancer treatment

The relationship between the oncologist and person is usually very strong with the oncologist often the main health professional involved. It can be difficult for the oncologist to move from a curative role to that of a counsellor when a person is requiring palliative care. Discussions are often started by the oncologist who guides the process. Clinical factors such as disease response and progression as well as the burden of side effects are the main considerations to begin the discussions to withdraw treatment. [7] The review by Clarke et al. [7] states that the patient-doctor relationship was a key part of decision-making concerning the withdrawal of anticancer drugs towards the end of life. This adds growing support to the body of knowledge on the importance of ‘trust’ and ‘rapport’ in shared healthcare decision-making.

The Australian OncPal deprescribing guideline was developed to support deprescribing of unnecessary or futile medications in palliative cancer individuals. [8] It helps by reducing costs, potential side effects and the burden of polypharmacy.

Medication deprescribing

According to the Australian Government Department of Health, the concurrent use of five or more medications is considered polypharmacy. [9] Deprescribing refers to the process of tapering or stopping medications, aimed at reducing polypharmacy and improving patient outcomes. [10]

Of the twelve systematic reviews, four focussed on deprescribing. [2,11-13] The Australian Government Department of Health has developed guiding principles for medication management in residential aged care facilities; these lack discussion on deprescribing. [9]

It is wise to approach deprescribing as a shared decision between a person and health care providers, and to address any concerns people or carers may have related to the deprescribing process. The use of multiple medications increases a patient’s risk of drug–drug interactions and adverse drug reactions and is an indicator of increased mortality risk among elderly people. [11]

There is one specific elderly population deprescribing tool developed in Ireland, STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy). STOPPFrail is a list of potentially inappropriate prescribing indicators designed to assist physicians with stopping such medications in older patients (≥65 years) who meet ALL the criteria listed below: (1) End-stage irreversible pathology (2) Poor one year survival prognosis (3) Severe functional impairment or severe cognitive impairment or both (4) Symptom control is the priority rather than prevention of disease progression. [10] This tool can be used with elderly people in any healthcare situation.

An article by Holmes HM et al. [12] highly recommended a randomised control trial by Kutner et al. (2015) that looked at the safety, benefits and challenges of discontinuing statin therapy. 

Evidence Gaps

  • There is little evidence around processes involved in stopping anti-cancer treatments other than clinical trials. More evidence based research is needed to support clinicians and patients in decision making regarding withdrawal of treatment. [7]
  • Among palliative specialists, there are some significant knowledge gaps about the law on withholding and withdrawing life sustaining treatment from adults who lack decision-making capacity. Steps should be taken to improve doctors’ legal knowledge in this area and to harmonise the law across Australia. [14]
  • Guidelines that incorporate deprescribing are greatly needed, particularly when counterbalancing clinical practice guidelines that recommend the initiation of preventive medication therapy without consideration of multimorbidity, advanced illness, or limited life expectancy. [12]
  • For end of life situations, very little rigorous research has been conducted on reducing inappropriate medications in frail older adults or those approaching end of life. [1]
  • Multimorbidity and polypharmacy are common, with protocols for stopping medication in these circumstances being scarce. [13]

Page updated 24 May 2017

 
  • References

  1. Tjia J, Givens J. Ethical framework for medication discontinuation in nursing home residents with limited life expectancy. Clin Geriatr Med. 2012 May;28(2):255-72.
  2. 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.
  3. Therapeutic Guidelines Limited. Therapeutic Guidelines: Palliative Care. Version 4. Melbourne: Therapeutic Guidelines Ltd, 2016.
  4. van Beinum A, Hornby L, Ward R, Ramsay T, Dhanani S. Variations in the Operational Process of Withdrawal of Life-Sustaining Therapy. Crit Care Med. 2015 Oct;43(10):e450-7.
  5. Melhado LW, Byers JF. Patients' and surrogates' decision-making characteristics: withdrawing, withholding, and continuing life-sustaining treatments. J Hosp Palliat Nurs. 2011 Jan-Feb;13(1):16-28.
  6. 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
  7. 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.
  8. 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.
  9. Australian Government Department of Health and Ageing. Guiding principles for medication management in residential aged care facilities [Internet]. 2012 Oct 23 [cited 2017 May 24]. 
  10. 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.
  11. Bemben NM. Deprescribing: An Application to Medication Management in Older Adults. Pharmacotherapy. 2016 Jul;36(7):774-80.
  12. Holmes HM, Todd A. Evidence-based deprescribing of statins in patients with advanced illness. JAMA Intern Med. 2015 May;175(5):701-2.
  13. van der Cammen TJ, Rajkumar C, Onder G, Sterke CS, Petrovic M. Drug cessation in complex older adults: time for action. Age Ageing. 2014 Jan;43(1):20-5.
  14. White B, Willmott L, Cartwright C, Parker MH, Williams G. Doctors' knowledge of the law on withholding and withdrawing life-sustaining medical treatment. Med J Aust. 2014 Aug 18;201(4):229-32.