Principles of medication rationalisation in palliative care

Medication rationalisation is a process of shared decision-making between healthcare professionals and patients to optimise benefit from each drug, and to reduce harm. For patients with palliative care needs, this process is informed by consideration of individual goals of care, health status, values, priorities, previous medication experiences, mental health wellbeing and location of care, combined with the healthcare professionals’ medication knowledge and the need for a practical regimen. Medication rationalisation in patients with palliative care needs may include deprescribing drugs without short-term benefits, changing drugs or formulations, and prescribing drugs for symptom management. Medication rationalisation must be pre-emptive and consider current as well as future needs.

Patients with palliative care needs often take many medications for a variety of reasons:

to treat their life-limiting illness or comorbidities
prevent complications
alleviate drug adverse effects
manage symptoms.

However, with the increase in number of drugs taken, there is also an increase in cost, risk of nonadherence, adverse effects, drug errors, and drug–drug and drug–disease interactions.

Start the process of medication rationalisation when palliative care is introduced. Early discussion of medication rationalisation gives patients, family and carers time to understand and prepare for potential changes to therapy. Incorporate a medication review into each clinical assessment to ensure that drugs are appropriate for the patient’s changing needs. To maximise safety, plan and monitor drug changes and communicate the changes to healthcare professionals involved in the patient’s care. Do not leave discussions about medication rationalisation until patients are in the last days of life or unable to swallow.

Note: Communicate any changes to drug therapy to all healthcare professionals involved in the patient’s care.

A suggested approach for medication rationalisation in palliative care is provided in A suggested approach to medication rationalisation in palliative care.

Table 1. A suggested approach to medication rationalisation in palliative care
[NB1] [NB2]
Collate a comprehensive drug list
A comprehensive medication reconciliation provides a starting point to discuss rationalisation with patients and their carers and other relevant healthcare professionals. Document the indication for each drug—consider: some drugs may have multiple indications drugs may have been prescribed by multiple prescribers patients may be uncertain of the history of, or reason for a drug liaising with the patient’s other healthcare professionals to determine the history and, ideally, make joint decisions about ongoing therapy patients may take over-the-counter and complementary and alternative medicines.
Discuss patient preferences and their understanding of each drug
Asking patients about their experience with each of their drugs can inform the individualised approach to medication rationalisation. Ask patients whether they feel their medications are beneficial, and if they prefer to continue to take them. This discussion can assist patients to make informed choices. Some patients are pleased or relieved to stop taking long-term drug therapy; for others, this idea can be very distressing.
Determine the ongoing need for each drug
In palliative care, drugs are primarily used for short-term benefit: either to relieve symptoms (eg analgesics) or prevent symptoms of chronic disease (eg antiepileptics). Drugs used for long-term benefit or to avoid long-term complications may have limited relevance in the setting of a short prognosis, and can often be stopped (eg lipid-modifying drugs). When reviewing each drug, ask ‘Why should this drug be continued?’ rather than ‘Why should this drug be stopped?’. Consider: the patient’s life expectancy and expected disease trajectory—will the drug provide benefit within their lifetime? the patient’s goals of care and preferences—is drug burden affecting quality of life? the balance between benefits and harms—does the drug provide more benefit than harm? the patient’s adherence—do they want to, or are they able to take the drug? Patients with advanced disease are often at greater risk of adverse effects because of changes in pharmacokinetics and pharmacodynamics due to a variety of causes including altered organ function and weight loss. Drug adverse effects may be difficult to distinguish from deterioration at the end of life. For example, sedation from a drug may be mistaken for deterioration due to disease progression or vice versa. Consider whether a change in drug is required because of worsening liver or kidney function (eg switching a DOAC to a LMWH). Consider deprescribing when the risk of harm outweighs potential benefits. Other patient concerns to consider are pill burden and medication cost. Continue drugs that are unlikely to cause harm but may improve quality of life (eg eye drops).
Discuss rationalisation with the patient
Engage in shared decision-making with the patient and their carer(s) or substitute decision-maker. Discuss: the reasons for proposed changes to drug therapy the process and any preferences they may have their fears and concerns. Try to address fears and concerns, which may include: fear of losing control of their health care concern about too many changes to their medications feeling that previous treatment has been futile worrying about contradictory recommendations of different prescribers fear that drug changes signify rapid disease progression or imminent death. Reassure patients and their carers that medication rationalisation is adjusting care to current and future needs. Sometimes it is helpful to ‘give permission’ to patients to stop their drugs. Occasionally a patient may decide to continue taking a drug despite the recommendation to stop or alter the drug regimen.
Prioritise drugs for rationalisation and plan the process
Make a plan for medication rationalisation with the patient, their carer(s) or substitute decision-maker, and relevant healthcare professionals. Identify drugs that: need a dose-reduction plan because they may cause withdrawal symptoms (eg antidepressants), symptom recurrence (eg drugs for Parkinson disease) or rebound effects (eg beta blockers) when abruptly stopped are highly specialised or require close monitoring, and would require specialist input for deprescribing (eg clozapine, mycophenolate, tacrolimus) will be required in the last days of life—consider whether a change in formulation, administration or drug will be required and make a plan for how and when to make these changes—see Anticipatory prescribing and Choice of route of drug administration in palliative care. Ideally, change one drug at a time; prioritise drugs with the highest burden. Use a sequential process and monitor for the return of previously managed symptoms, adverse effects or withdrawal signs. Aim to have all unnecessary drugs stopped before the patient becomes unable to swallow or reaches the last days of life. If possible, document the process; as relevant, set out: the order of drugs to be deprescribed or changed reasons for rationalisation of each drug the process of dose reduction or cessation, and indicators to resume the drug the process of drug introduction or formulation change monitoring requirements.
Communicate changes to drug therapy
Communicate any changes to drug therapy to all healthcare professionals involved in the patient’s care.
Regularly reassess drug therapy
The benefit–harm profile of drugs can rapidly change in patients with palliative care needs; regular re-evaluation is vital.
Note: DOAC = direct-acting oral anticoagulant; LMWH = low molecular weight heparin NB1: Ethical aspects of withdrawing or withholding treatment are discussed in Withdrawing or withholding treatment in palliative care. NB2: Staged rationalisation may not be possible for patients who deteriorate rapidly and have reduced consciousness. At this point, it may be necessary to suddenly stop oral drugs; some may need to be continued via a different route to prevent or relieve symptoms (eg antiepileptic drugs for seizures). For choice of route of drug administration, see Choice of route of drug administration in palliative care.

A variety of resources are available to assist with medication rationalisation and deprescribing; however, some tools prioritise deprescribing drugs necessary for symptom management (eg opioids), which may not be appropriate for patients with palliative care needs. The following resources can support deprescribing in patients with palliative care needs, but their recommendations should always be considered in the context of the individual patient’s goals of care, values and priorities:

Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail) version 2¹ Curtin, 2021—identifies older people likely to be approaching the end of life and includes 25 deprescribing criteria.
the OncPal deprescribing guideline² Lindsay, 2015—lists potentially inappropriate medicines that assists deprescribing in patients who have cancer with an estimated prognosis of less than 6 months.
deprescribing.org—provides deprescribing guidelines and algorithms for healthcare professionals on commonly used drugs and information pamphlets for consumers.
Primary Health Tasmania Deprescribing resources—provides guidance for healthcare professionals on deprescribing commonly used drugs.

¹ Curtin D, Gallagher P, O’Mahony D. Deprescribing in older people approaching end-of-life: development and validation of STOPPFrail version 2. Age Ageing 2021;50(2):465-71. [URL]Return

² 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;23(1):71-8. [URL]Return