Discussing Cessation of Medications Near the End of Life

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Discussions with patients and families about stopping non–cancer-related medications near the end of life are thorny but necessary, according to Arif H. Kamal, MD, of Duke Cancer Institute, at the Best of ASCO meeting in Seattle.

“What’s happening now is that a lot of hospices are having a conversation with patients because of financial reasons. So there is a lot more scrutiny now because of accurately shifting medications to Medicare Part D, which is where a lot of these should be vs being covered by the hospices themselves. Now, hospices have to go through every single medication and either put it on the Part A side, which is the hospital benefit, or the Part D side [the drug benefit], and at the same time indicate whether it is for quality of life or not, and whether it needs to be continued or not, whether it is essential or not,” he explained. “It’s a delicate conversation.”

For example, in patients who have had a pulmonary embolism and are now on heparin or a similar agent, oncologists may need to have a discussion about CHADS2 risk scores (congestive heart failure, hypertension, age, diabetes, and prior stroke, transient ischemic attack, or thromboembolism) and how they apply over various time periods. “I think ultimately if you talk to patients about what their goals are and what’s important to them, and ask them if, by stopping [warfarin], what they’re afraid of, and they say I’m afraid of having a stroke or that kind of thing, then you can address that,” Dr. Kamal said. ■

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