Why patients at the end of life may not be receiving the best care

Providing comfort care should be the first priority for those nearing the end

Reading Time: 4 minutes

By James Downar
University of Toronto
and John Muscedere
Queen’s University

Our health-care system focuses on fixing everything we can when a patient is ill. But when someone is nearing the end of life, this approach may no longer be what the patient and their families need or want most. And it may mean such patients don’t receive the best care.

When someone is admitted to hospital, the focus is often on reversing acute conditions rather than providing comfort care for patients, even when they have little time left. This may lead to the use of drugs or other medical interventions that offer little benefit. And, significantly, it could lead to the avoidance of comfort medications for patients in extreme stress or pain.

James Downar
James Downar

For example, a person with advanced lung cancer is probably not going to benefit from cholesterol medication, but they may benefit from a drug that treats pain or shortness of breath. Or a person with severe heart failure is probably not going to benefit from a medication to prevent osteoporosis, but they might benefit from medications to improve their sleep or mood.

Using non-beneficial medications or failing to offer comfort medications is potentially harmful, time-consuming and simply bad medical care. Unnecessary or unwarranted interventions, including medications, are also costly to the health-care system.

Canadians are living longer and the accumulation of chronic illnesses as people age has led to increased use of pharmaceuticals for chronic conditions, such as diabetes or high blood pressure. The Canadian Institute for Health Information reports that medications represent the second largest component of health-care spending after hospitals — approximately $29 billion a year.

There is a clear and steady increase in chronic conditions treated in seniors. More than half of Canadian seniors take medications to treat two or more chronic conditions. A quarter of seniors are on medications to treat three or more conditions.

More than 60 per cent of Canadian seniors take five or more medications from different drug classes and over 20 per cent have insurance claims for 10 or more per year. A whopping 30 per cent of those over the age of 85 claim 10 or more drugs.

Modern medicines have improved the quantity and quality of our lives. But what should we do with medications that treat chronic conditions as the end of life nears?

John Muscedere
John
Muscedere

At the Technology Evaluation in the Elderly Network and the University Health Network in Toronto, we’ve been examining the impact of assigning a “medication rationalization” team of physicians, pharmacists and nurses to review medications prescribed to patients with advanced illness. The team makes recommendations on stopping any non-comfort medication that has no clear benefit to the patient and suggests comfort medications. These recommendations are presented to the patient or decision maker and changes are made with consent.

The response among the 60 patients involved in the study to date has been overwhelmingly positive. Patients and family are happy to receive expert recommendations that stop medications that are no longer helpful.

It was once believed that patients would get upset if a doctor suggested they stop taking a long-standing medication — as if it were an admission of defeat by patient or doctor. On the contrary, patients and family members in our study ask a lot of questions and are comfortable voicing concerns or disagreement. The patient’s voice then becomes part of the process and helps to improve end-of-life care.

The concern that some patients would feel doctors were trying to save money by stopping medications has also proven to be unfounded. Our study has found that patients are usually very comfortable stopping some medications and starting others because they also believe it is the right thing to do.

It is entirely beneficial to re-examine the goals of treatment at end of life. Even a brief conversation with patients and families about symptoms, fears, support needs and treatment preferences can identify important ways to provide better care.

Dr. James Downar is a Critical Care and Palliative Care Physician at the University Health Network and Sinai Health System in Toronto, and an Associate Professor in the Department of Medicine at the University of Toronto. John Muscedere is the scientific director and CEO of the Canadian Frailty Network (CFN), a not-for-profit organization funded in 2012 by the government of Canada’s Networks of Centres of Excellence (NCE) program. He is also a professor in the School of Medicine at Queen’s University, and an intensive care physician at Kingston General Hospital.

James and John are Troy Media Thought Leaders. Why aren’t you?

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A message from our Editor

An aging Canadian population and smaller families, combined with reduced health and social care budgets, mean the challenges of providing care to seniors will only worsen. Legions of families are buckling under the emotional, physical and fiscal burdens of caregiving. These pressures will be exacerbated by growing numbers of people living with demanding health challenges such as dementia, with fewer and fewer people to take care of them. The natural web of caring that so many of us take for granted is at risk of unravelling. Troy Media’s Family Ties examines the issues facing caregivers and the health-care system in general and seeks solutions. If you have a story to tell, contact us at familyties@troymedia.com

James Downar

Dr. James Downar is a Critical Care and Palliative Care Physician at the University Health Network and Sinai Health System in Toronto, and an Associate Professor in the Department of Medicine at the University of Toronto. He graduated from McGill Medical School and completed residency training in Internal Medicine, Critical Care and Palliative Care at the University of Toronto. He has a Master’s degree in Bioethics from the Joint Centre for Bioethics at the University of Toronto. He is the Program Director for the Subspecialty Residency Program in Palliative Care at the University of Toronto, the chair of the Postgraduate Education Committee of the Canadian Society of Palliative Care Physicians, and the chair of the Ethical Affairs committee of the Canadian Critical Care Society. He has authored more than 50 peer-reviewed publications, has been principal investigator on nine peer-reviewed grants, and is an Associated Medical Services Phoenix Fellow for 2016-7. His research interests include communication and decision-making for seriously ill patients and their families; Palliative Care for the Critically Ill; and Palliative Care for Noncancer Illnesses.

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