Clinical tips: palliative care

woman taking pills

It’s important to look into whether use of certain medicines is appropriate for people with life-limiting illnesses,writes Ben Basger

Pre-existing medical conditions commonly occur in people with life-limiting illnesses. Generally, additional medicines are added to these pre-existing medicines for control of terminal symptoms.

A concern is that medicines for comorbid conditions, especially for secondary prevention, may be continued for longer than clinically indicated.

Examples of medicines for secondary prevention are aspirin, statins and medicines for osteoporosis. Examples of medicines treating comorbid conditions are proton pump inhibitors, complementary and alternative medicines, oral hypoglycemics and antihypertensives (J Am Geriatr Soc 2007; 55:590-5, Support Care Cancer 2015; 23:71-8).

The question arises as to whether continuation of medicines that are no longer clinically indicated may contribute to functional decline. Could it be that there is an exaggerated response to pre-existing medicines due to a rapidly changing body? Might some functional decline be due to adverse medicine interactions? Perhaps medicines for comorbid conditions could/should be more actively managed.

Do you have patients in the terminal phase of an illness on some of the medicines listed above?

When new medicines are added to pre-existing medicines for symptom control, cost and burden increase. By burden we mean management issues such as; what is it? where is it? when do I take it? where do I get more? will it cause side effects? how much or how little should I take? will it keep working? can I take more if I need it?

Would people in the terminal phase of an illness manage better with more medicines or less medicines?

We know that cancer patients who have transitioned from surgery, chemotherapy or radiotherapy intended for cure to palliative therapy often remain on medicines with potentially harmful effects or no short-term benefit.

The focus of care should be to improve a patient’s quality of life. Yet we know that many patients receive (potentially) inappropriate medicines. Should we be doing more questioning?

Medicines commonly commenced for symptom control include opiates, paracetamol, dexamethasone, a benzodiazepine and metoclopramide.

Sometimes more than one benzodiazepine may be used, for which there appears to be no rationale. This is particularly so when clarity of thought and confidence with movement – both compromised by these medicines – may add enormously to one’s quality of life.

Would a shorter acting benzodiazepine be better than a longer acting one? Would domperidone provide a safer alternative to metoclopramide? Is the use of one laxative sufficiently effective?

These and other questions need to be asked in our care of the terminally ill.      

Dr Ben Basger PhD MSc BPharm DipHPharm FPS AACPA is a clinical pharmacist and educator at Wolper Jewish Hospital and The University of Sydney, NSW.

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