Emphasizing Quality of Life Over Quantity of Life
LAS VEGAS—The goals of care change near the end of life, shifting from an emphasis on “quantity of life” to “quality of life,” said Mary Lynn McPherson, PharmD, MA, BCPS, CPE, Professor of Pharmacy Practice and Science at the University of Maryland School of Pharmacy in Baltimore, Maryland to attendees at PAINWeek 2014.
Improving quality of life for the terminally ill means avoiding unnecessary blood draws and “deprescribing” – ending prescriptions that lack clear indications, for example.
Deprescribing at end of life involves identifying and prioritizing which drugs to stop, and monitoring to assess safety and effectiveness. Anticoagulant prescriptions can usually be switched to aspirin for end-of-life patients, for example. “It is ok to have a blood pressure of 150 at the end of life,” Dr. McPherson said. Glycemic control goals should be liberalized at the end of life – perhaps even as liberal as a blood glucose of 140-250 mg/dL (provided the patient is not symptomatic).
Diabetes is frequently mismanaged at the end of life, she noted. Tighter glycemic control in the last weeks of life is not always better, she said. “I have no interest in A1c in a hospice or palliative care patient. Unless they're symptomatic, I'm not terribly concerned about blood sugar, either.” Performing finger stick to check the blood glucose, and potentially administering up to four doses of insulin a day doesn't seem particularly palliative!
Challenges to deprescribing include patient or family resistance. Physical dependence is another challenge.
Agitation, delirium, anxiety and depression are common at the end of life and can complicate pain management, she reported. “We see a lot of overlap in these mental health conditions,” Dr. McPherson said. “We see an awful lot of delirium in end-of-life care. Patients can be right as rain in the morning and then as the sun starts to go down, people can go off the deep end.” But treating end-of-life delirium with benzodiazepines can backfire, worsening symptoms, Dr. McPherson cautioned. “Lorazepam is not your friend here.”
Be generous in treating breakthrough pain, she advises. But for conversions, keep in mind that “you cannot chase a changing pain picture with an agent that takes days to achieve steady state.”
“There are many conversions we can use” for methadone, she said. “There are like 8 million methods of converting methadone and here's the kicker: they all work.”
“My own personal new line in the sand is I never go above 10 mg (of methadone), three times a day,” she said. Patients should be closely monitored during the first five days after starting methadone, she said. Difficulty rousing and increased snoring are red flags for methadone toxicity. There's up to a 30-fold variability in liver metabolism of methadone, depending on patients' CYP3A4 activity, she noted.
Many end-of-life patients are candidates for methadone, Dr. McPherson believes. “Who is inappropriate? Maybe somebody who is really close to death.”