Adjustment of pharmacotherapy during the final days of life in home hospice care: a pilot retrospective study

Introduction

End-of-life care requires a multidisciplinary and compassionate approach, addressing patients’ and their caregivers’ clinical needs and personal preferences. In the terminal phase of life, pharmacotherapy primarily focuses on symptom relief, aiming to enhance quality of life and reduce distressing symptoms such as pain, dyspnea, and anxiety (1). As patients approach the end of life, medication reassessment is crucial to identify no longer beneficial or appropriate medications, replacing them with those focused on symptom management (2). Specifically, in Home Hospice Care (HHC), this process becomes even more critical, allowing patients to remain in the comfort of their homes, surrounded by loved ones. It is essential to understand how pharmacotherapy changes during the last days of life in HHC, as this may offer insights into which medications are most frequently discontinued or adjusted (3-6). Moreover, with the increasing availability of potent drugs with systemic and targeted effects, new challenges arise for patients in palliative care, particularly in optimising treatment for comfort while minimising unnecessary interventions (7,8).

Palliative care is often confused with hospice care. Both are focused on providing comfort; hospice care explicitly addresses the end-of-life period for patients with a life expectancy typically less than 6 months. One key difference in pharmacotherapy between the early and late stages of an incurable illness lies in the shift from general clinical recommendations to adjustments based on the qualitative and quantitative changes in the patient’s symptoms. This can involve collaborating with physicians and clinical pharmacists within a multidisciplinary team to ensure appropriate and effective medications (9,10). The goal is to optimise pharmacotherapy individually, taking into account the current clinical symptomatology and the preferences of both the patient and caregivers (11,12).

Our retrospective, non-randomised study provides clues to which drugs or drug classes may contribute to drug-related problems (DRPs) in terminal patients. These findings can help tailor pharmacotherapy to meet individual patient needs, ultimately improving the quality of life in the final days of life. We present this article in accordance with the CREDES reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-24-146/rc).

Methods

Study design and participants

Fifty closed medical records of patients treated between 12/2022 and 7/2023 were evaluated in the Home Hospice Care of the Regional Charity Hradec Kralove. Patients included in the retrospective, non-randomised mini-study were selected consecutively without any selection and represented 42% of patients in HHC over the past year. This retrospective pilot study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Ethics Committee of the University Hospital Hradec Kralove (No. 202405 P04). Since this was a retrospective study using data from deceased patients, obtaining their signed informed consent was not possible. However, written informed consent was approved from the HHC management before the study.

Inclusion required:

• Age ≥18 years.
• Terminal disease with curative treatments exhausted.
• Patient and caregiver consent for HHC and 24-hour caregiver presence.
• Residency within 30 km of Hradec Kralove.

The primary terminal diagnoses were solid tumours [42 patients (84%)], hemato-omcological diseases [2 patients (4%)] and terminal non-oncologicla diagnoses [end-stage heart failure: 3 patients (6%), end-stage Alzheimer’s disease: 2 patients (4%)] and 1 frail geriatric patient without reserves with acute uroinfection. Table 1 summarises the descriptive characteristics of the monitored group of patients, including the primary terminal diagnosis. In addition to the terminal diagnosis, other treated diagnoses were also recorded in the patients (see the last row of Table 1).

The patient can request admission to the HHC, general practitioner, or the attending physician at any healthcare facility where they are cared for before being transferred home. The decision to admit a patient to the HHC is made by the admitting physician at HHC, who evaluates the patient’s medical condition, confirms the completion of active treatment, and ensures that a written agreement is in place with the patient and the caregiver, who must be able to guarantee 24-hour care. Admission is also contingent on the availability of resources at HHC. There are no additional entry criteria or restrictions. Once admitted, patients receive 24-hour/7-day nursing care and have 24-hour/7-day access to consultation with an HHC doctor. Depending on the patient’s needs, other multidisciplinary team members such as social workers, psychotherapists, clergy, clinical pharmacists, and volunteers can provide support. HHC services are covered by health insurance.

Measures

This study follows the completed Czech Health research project titled “Analysis of Factors Influencing the Quality of Life of Patients in Palliative Oncology Care—Personalised Approach in a Specialized Outpatient Clinic” (13).

The clinical pharmacist in the palliative team reviewed and processed data on pharmacotherapy for each patient from the day they entered HHC until their death. Pharmacotherapy was adjusted from treatments focused on chronic disease management to therapies aimed at maximising symptom relief and enhancing quality of life during the final stages. Along with changes in the medication regimen, there was often a shift in routes of administration, particularly as oral intake became limited or no longer feasible. In palliative care, subcutaneous administration is commonly employed due to its effectiveness and ease of use.

Data collection

The data for this retrospective study were obtained from anonymised data from closed-paper medical records of HHC patients. A closed medical record refers to a patient’s complete medical documentation, finalised by the attending physician after the end of patient care, which, in the case of HHC, occurs after the patient’s death. These medical records include essential information such as the primary terminal diagnosis, all prescribed and administered medications, procedures performed, and other pertinent health and care details. Once finalised, the medical records are no longer modified and archived per HHC’s legal and organisational rules, ensuring the confidentiality and security of patient data.

The selection of 50 records for this small, retrospective study was made to ensure a sufficiently large sample size, allowing for the identification of trends and the capture of symptoms or complications that may have been overlooked or could have been ignored in smaller studies. This sample size also provided a manageable scope for analysis within the available time and resources, with data processing conducted by a single clinical pharmacist in the palliative care team. Notably, these 50 patients represent 42% of those who received care during 1 year.

Pharmacotherapy was evaluated according to Czech legislation regarding the clinical-pharmaceutical evaluation of risky drugs and drug groups that could be associated with DRPs. Table 2 provides an overview of the identified risk groups and their occurrence.

Statistical analysis

Descriptive statistics are expressed as mean and standard deviation (SD) or frequency where appropriate. A paired t-test was used for repeated measures. A P value <0.05 was considered statistically significant. Data were analysed using JASP (version 0.19.0, Apple silicon, https://jasp-stats.org/) and Jamovi [version 2.5.7.0 (2024), https://jamovi.org].

Results

Pharmacotherapy analysis

In the cohort of 50 patients, initial pharmacotherapy was assessed upon admission to the HHC. The average number of systemic medications was 5.52 (SD 2.88), with a minimum of 1 drug and a maximum of 12. Thanks to the clinical pharmacist’s professional skills and qualifications, medication reconciliation was performed to identify potentially risky medications associated with possible DRPs (14-16). The most common medications linked to DRPs captured in this population are summarised in Table 3.

As a part of the palliative care plan, it is essential to evaluate each patient’s medications thoroughly, assessing their appropriateness and indication in the context of the patient’s current condition. Key factors to consider include whether the medication should continue in the final days of life, the safety of the original dosages (considering factors such as oral intake, ability and signs of renal or hepatic dysfunction), the effectiveness of the treatment, and any potential adverse effects, that may worsen the patient’s discomfort. Changes in pharmacotherapy are often necessary due to shifts in the patient’s condition, such as the inability to take oral medications (e.g., in cases of coma or sopor) or progression of renal or hepatic failure (e.g., anuria or jaundice). Table 4 provides examples of pharmacotherapy adjustments implemented in the final days of life.

End-of-life symptoms

The most common symptoms encountered by patients were recorded. In total, 15 primary symptoms were identified, with pain being the most prevalent in 28 patients (56%). Additionally, 16 symptoms labelled as “other” occurred only once in the cohort and were documented: ascites, insomnia, discomfort, ileus, hiccups, constipation, dementia progression, coagulopathy, dysphagia, oedema, aggression, melena, loss of swallowing, cough, anorexia and hallucinations. The frequency of symptoms is presented in Figure 1.

Figure 1 Recorded symptoms in the group of patients.

End-of-life pharmacotherapy

Pharmacotherapy was reevaluated on the day of death. Patient care at HHC lasted 1–34 days (mean 10.06 days, SD 8.33).

The mean number of systemic medications prescribed was 2.64 (SD 1.27), with a minimum of 1 drug and a maximum of 6. Figure 2 shows an overview of medicines on the day of death.

Figure 2 Medications on the day of the patient’s death.

Regarding the route of administration, the majority of medications were administered subcutaneously. One patient received transdermal fentanyl; another had morphine and bupivacaine via an epidural catheter, and several patients received medications in the form of oral drops (e.g., morphine, haloperidol, or a fixed combination of metamizole and pitofenone).

Given that pain was the dominant symptom addressed in patients, a more detailed analysis of pharmacotherapy on the final day focused on analgosedation, the medications used and their doses administered via subcutaneous linear driver (LD). Of the 50 patients, 26 (52%) were transitioned to continuous subcutaneous medicines at the end of life. A subcutaneous LD containing two components was used in 12 patients (46.2%), while 14 patients (53.8%) received a mixture of three components for analgosedation. Specific details on the composition of these drug mixtures and the number of patients receiving each combination are shown in Figures 3,4.

Figure 3 Two-components final mixture in subcutaneous LD. LD, linear driver.

Figure 4 Three-components final mixture in subcutaneous LD. LD, linear driver.

The most common components in the continuous drug mixtures included analgesics, anxiolytics, sedatives, and antipsychotics used to manage restlessness, delirium, agitation and anxiety, or antiemetics for nausea/vomiting. Patients and their caregivers were trained to operate the subcutaneous LD and administer a bolus of the mixture if necessary. Each patient with a 24-hour subcutaneous LD had morphine as one of the components, while other medications included midazolam, haloperidol, and levomepromazine. The dosages of these components in the subcutaneous LD are summarised in Figure 5. The clinical pharmacist verified the compatibility and 24-hour stability of the drug mixtures used in subcutaneous LD.

Figure 5 Final dose of selected drug in subcutaneous LD. %, percentage of patients with an indicated daily dose of selected drug in LD. LD, linear driver.

Discussion

Hospice care is aimed at maximum patient comfort on the final day of life and is provided by specialised palliative care specialists (8,17,18). Palliative care in the Czech Republic is no longer an extended taboo, with an increasing number of palliative and non-hospital care in hospices or home hospices (1,19).

Integration of findings with existing literature

The results of our small study underscore the importance of tailored pharmacotherapy in terminal hospice care, particularly regarding the reduction of polypharmacy and the shift to symptom-focused treatment. Hospice care is intended for oncology patients and all patients with terminal illnesses. In our group, patients with a primary oncological diagnosis predominated: 44 patients (88%) had a prominent (hemato)oncological diagnosis, and 6 patients (12%) had a non-oncological terminal disease.

Our findings demonstrate a significant reduction in the mean number of systemic medications, from 5.52 to 2.64 (P<0.001), reflecting the goals of palliative care to prioritise symptom relief and improve quality of life. This reduction is consistent with previous studies that have highlighted the risks associated with polypharmacy in terminal patients, especially in the context of DRPs (1,2). In line with these findings, we observed that common drug groups associated with DRPs in our cohort included antidepressants, sedatives, antihypertensives and gastroprotection. These classes of drugs are frequently identified as potentially inappropriate for patients in the terminal phase of life, where their clinical relevance diminishes, and the risks often outweigh the benefits (3).

Our study also confirms that the international recommendation for his approach reflects global palliative care practices, where subcutaneous administration is considered the method of choice for managing symptoms in terminal patients (16,20). Our study also confirms the international recommendation to prefer subcutaneous administration of drugs. Final continuous subcutaneous analgosedation was used in 52% of our cohort. Subcutaneous routes are particularly advantageous due to their simplicity, efficacy and ease of use in the home hospice setting, especially in patients with limited venous access (4,5). This is in line with palliative clinical, which emphasises the use of subcutaneous administration for pain, dyspnea, and other common terminal symptoms, as it is less invasive than intravenous methods and can be effectively managed by both healthcare professionals and caregivers, the only possible parenteral administration of medication from a forensic perspective for non-medical personnel.

Clinical pharmacists play a significant role in the multidisciplinary palliative care team. Medical reconciliation can evaluate medication efficacy, identify DRPs and optimise routes of drug administration (19). Pharmacists help improve patient safety and enhance quality of life during end-of-life. The most frequently used drugs (morphine, midazolam, haloperidol) were following published recommendations for management in end-of-life care (14,15,20-25). Our study confirmed the exceptional position of morphine for multiple effects, a wide dosage range and cost-effectiveness. It is also favourable from a pharmacoeconomic point of view. However, the unavailability of certain registered drugs (e.g., levomepromazine) in the Czech Republic presents a challenge, often requiring the use of unregistered medicines.

Limitations of the study

While our study provides valuable insights into the pharmacotherapy of terminal patients in HHC, several limitations must be acknowledged. The study’s retrospective design and small sample size limit the generalizability of the findings. Future prospective studies with larger cohorts are needed to validate our findings and explore the implications of medication transitions in the last days of life. Moreover, additional research could focus on patient-centred outcomes, such as symptom control and caregiver satisfaction, to better assess the holistic impact of pharmacotherapy adjustments in the terminal phase.

Conclusions

• This retrospective study provided a comprehensive evaluation of pharmacotherapy for patients in the terminal phase of life who received care in their home environment with the support of a multidisciplinary HHC team.
• The study identified and tracked the most common symptoms observed in terminal patients, along with their frequency of occurrence.
• A key contribution of the study project was monitoring pharmacotherapy changes from admission to HHC to the patient’s final day of life, providing insight into the evolution of treatment during the terminal phase.
• The use of off-label administration methods and unregistered drugs was also documented, highlighting the flexibility needed in end-of-life care when standard treatments are unavailable.
• Detailed analysis was conducted on the multi-component drug mixtures administered via subcutaneous LD, which is commonly used for symptom management in palliative care.
• The primary limitation of this study is its small sample size and the retrospective design. A prospective study with a larger cohort and closer involvement of the clinical pharmacist in the care team could provide more robust data and further insights into pharmacotherapy in end-of-life care.

Acknowledgments

We extend our profound gratitude to the patients and caregivers who participated in this study.

Footnote

Reporting Checklist: The authors have completed the CREDES reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-24-146/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-146/dss

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-146/prf

Funding: The Ministry of Health of the Czech Republic (NU20-09-00045) supported the present study.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-146/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This retrospective pilot study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Ethics Committee of the University Hospital Hradec Kralove (No. 202405 P04). Since this was a retrospective study using data from deceased patients, obtaining their signed informed consent was not possible. However, written informed consent from the HHC management was obtained before the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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