Pharmacological management of co-morbid conditions at the end of life: is less more?

Co-morbid conditions (CMCs) are present in over half of patients with cancer over 50 years of age. As life-limiting illnesses progress, the benefits and burdens of treatments for CMCs become unclear. Relevant issues include physiological changes in advanced illness, time-to-benefit of medications, burden of medications, and psychological impact of discontinuing medications. Optimal prescribing is unclear due to lack of evidence. The objectives are to determine prescribing practice, for CMCs, in a single SPC service. Patients referred to a single specialist palliative care (SPC) service, who died between 1/8/2010 and 30/9/2012, were identified. Medical notes were reviewed, and data collected on prescribing at 3 months, 1 month, and 1 week prior to death. Fifty-two patients with a median age of 74.5 years were identified; 41 patients (79 %) had a malignant condition. 50 % died in hospital. Patients had a mean of three CMCs. A mean of 4.6 medications for CMCs were prescribed to patients over 65. A mean of 10 medications in total were prescribed at 1 week before death. One week before death, one-third of patients continued to be prescribed aspirin, and over one-quarter a statin. Total medication burden increases as time to death shortens, due to continuation of medications for CMCs, and addition of medications for symptom control. There is a need for research to demonstrate the impact of polypharmacy at the end of life, in order to formulate a framework to guide practice.