Drug treatment at the end of life: An epidemiologic study in nursing homes

Abstract

Objective. To examine drug treatment in nursing home patients at the end of life, and identify predictors of palliative drug therapy. Design. A historical cohort study. Setting. Three urban nursing homes in Norway. Subjects. All patients admitted from January 2008 and deceased before February 2013. Main outcome measures. Drug prescriptions, diagnoses, and demographic data were collected from electronic patient records. Palliative end-of-life drug treatment was defined on the basis of indication, drug, and formulation. Results. 524 patients were included, median (range) age at death 86 (19–104) years, 59% women. On the day of death, 99.4% of the study population had active prescriptions; 74.2% had palliative drugs either alone (26.9%) or concomitantly with curative/preventive drugs (47.3%). Palliative drugs were associated with nursing home, length of stay > 16 months (AOR 2.10, 95% CI 1.12–3.94), age (1.03, 1.005–1.05), and a diagnosis of cancer (2.12, 1.19–3.76). Most initiations of palliative drugs and withdrawals of curative/preventive drugs took place on the day of death. Conclusion. Palliative drug therapy and drug therapy changes are common for nursing home patients on the last day of life. Improvements in end-of-life care in nursing homes imply addressing prognostication and earlier response to palliative needs.

End‐of‐life treatment decisions in nursing home residents dying with dementia in the Netherlands

“…A study from Norway in a general nursing home population also found that changes in drug treatment were made just at the day of death (Jansen et al . ).…”

Prescription and Deprescription of Medication During the Last 48 Hours of Life: Multicenter Study in 23 Acute Geriatric Wards in Flanders, Belgium

“…7,9,10 As it has been shown that very old patients have lower requirements in the dose of medications, we focused mainly on the presence of an anticipatory prescription during the last 48 hours of life as an indicator of optimal symptomatic care. 28 If compared with results from other studies investigating the anticipatory prescription of medication for patients with cancer in acute hospital care 19,20 and of older patients in a nursing home setting, 6,18 the anticipatory prescription of morphine (45.5%), benzodiazepine (15.5%), and scopolamine (13.8%) in our study population was lower than that reported in a Dutch cancer population (53%, 23%, and 25%, respectively) 20 and that reported in a nursing home population in Norway (82.6%, 70.4% and no reported data for antisecretory drugs, respectively). 18 This rate of opioid prescription at the end of life can be supported by a recent study in Dutch nursing homes reporting an increase in prevalence of pain in 78% and shortness of breath in 52% of the dying population with dementia.…”

“…Moreover, the criteria for discontinuance of medication are heterogeneous, ranging from well-standardized and validated appropriateness criteria such as Beers, START/STOPP to more implicit criteria taking into account the overall health condition, such as the Medication Appropriateness Index and the Good Palliative-Geriatric Practice algorithm. 17 Up to now, there have been few epidemiologic studies describing pharmacological management in nursing homes 18 and among cancer patients at the end of life, 19e23 none of which address the subject of pharmacological management during the last days of life of frail older people on a specialized acute geriatric ward. Therefore, this study aims to describe the anticipatory prescription of symptomatic medication and the deprescription during the last 48 hours of life on acute geriatric wards as well as the relationship between medication practice and patient characteristics such as dementia.…”

Associations between Length of Stay in Long Term Care Facilities and End of Life Care. Analysis of the PACE Cross-Sectional Study

“…In particular, it is unclear whether the end of life care received by residents admitted shortly before death differs from the care for those who have lived in a facility for many months or even years [29]. Previous studies exploring care at end of life have found that residents with longer length of stay before death had fewer hospitalisations, were more likely to be receive palliative drug therapy, less likely to be undertreated for non-pain symptoms and more likely to have documented do-not-resuscitate (DNR) orders in place [30][31][32][33].At present, no published research has specifically explored the association between length of stay in a LTCF and the experience of residents at end of life, collected either directly from the resident or by proxy measures. None of the research previously discussed included length of stay as a primary explanatory variable of the end of life care indicators investigated, and none report conducting any prior analysis to explore factors associated with length of stay in the data.…”

“…In particular, it is unclear whether the end of life care received by residents admitted shortly before death differs from the care for those who have lived in a facility for many months or even years [29]. Previous studies exploring care at end of life have found that residents with longer length of stay before death had fewer hospitalisations, were more likely to be receive palliative drug therapy, less likely to be undertreated for non-pain symptoms and more likely to have documented do-not-resuscitate (DNR) orders in place [30][31][32][33].…”