Continuation of non-essential medications in actively dying hospitalised patients.

OBJECTIVE: The objective of this analysis was to examine the use of 11 non-essential medications in actively dying patients. METHODS: This was a planned secondary analysis of data from the Best Practices for End-of-Life Care for Our Nation's Veterans trial, a multicentre implementation trial of an intervention to improve processes of end-of-life care in inpatient settings. Supported with an electronic comfort care decision support tool, intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients/families and implement best practices of traditionally home-based hospice care. Data on medication use before and after intervention were derived from electronic medical records of 5476 deceased veterans. RESULTS: Five non-essential medications, clopidogrel, donepezil, glyburide, metformin and propoxyphene, were ordered in less than 5% of cases. More common were orders for simvastatin (15.8%/15.1%), calcium tablets (8.4%/7.9%), multivitamins (11.6%/10.8%), ferrous sulfate (9.1%/7.6%), diphenhydramine (7.2%/5.1%) and subcutaneous heparin (29.9%/27.5%). Significant decreases were found for donepezil (2.5%/1.3%; p=0.001), propoxyphene (0.8%/0.1%; p=0.001), metformin (0.8%/0.3%; p=0.007) and multivitamins (11.6%/10.8%; p=0.01). Orders for one or more non-essential medications were less likely to occur in association with palliative care consultation (adjusted OR (AOR)=0.64, p<0.001), do-not-resuscitate orders (AOR=0.66, p=0.001) and orders for death rattle medication (AOR=0.35, p<0.001). Patients who died in an intensive care unit were more likely to receive a non-essential medication (AOR=1.60, p=0.009), as were older patients (AOR=1.12 per 10 years, p=0.002). CONCLUSIONS: Non-essential medications continue to be administered to actively dying patients. Discontinuation of these medications may be facilitated by interventions that enhance recognition and consideration of patients' actively dying status.

Intermittent subcutaneous furosemide: parenteral diuretic rescue for hospice patients with congestive heart failure resistant to oral diuretic.

Patients with congestive heart failure (CHF) account for up to 12% of the hospice population and often experience significant symptoms related to volume overload. Diuretic therapy is the cornerstone of treatment but administration (PO) often becomes ineffective and (i.v., i.m.) routes cause discomfort or may not be feasible to ameliorate symptoms. Subcutaneous dosing of furosemide has been explored as a potential alternative for management of CHF symptoms. We report 2 cases of CHF resistant to oral diuretic and examine the clinical utility of subcutaneous furosemide in an inpatient palliative care unit and a home hospice setting. Our case series supports the use of subcutaneous therapy as a potential alternative in palliative care and hospice patients.