Published in the July 2006 issue of Today’s Hospitalist
Talk to Holly M. Holmes, MD, about discontinuing medications in elderly patients near the end of life, and the conversation will likely turn to examples of strategies that she thinks are not approÂ¬priate. She does not believe that statins should be withheld from all frail, elderly patients, for example, and she in no way supports the notion of undertreating those patients.
There’s a reason that Dr. Holmes stakes out her position on disÂ¬continuing medications in the elderly using negative examples. Since a commentary she wrote on the topic was published in the spring, she has spent a fair amount of time dispelling misconcepÂ¬tions about her views.
The article, which appeared in the March 27, 2006, Archives of Internal Medicine, calls on physicians to take a rational approach when managing the laundry lists of medications being taken by many frail and elderly Americans. Dr. Holmes and her colleagues propose a decision-making model to evaluate whether those drug regimens are really serving patients.
While the model may be simple, it doesn’t always resonate with physicians. Some of the residents Dr. Holmes works with, for example, believe that she opposes drugs for elderly patients.
“I’m not advocating for the undertreatment of the elderly,” she emphasizes. “I’m advocating for better treatment for people in whom overtreatment is not the answer.”
A rational approach
In the commentary, Dr. Homes and three of her colleagues propose a framework for discontinuing medications in the elderly who are near the end of their lives. The model examines four factors: the patient’s life expectancy, the time until a therapy will produce a benefit, the patient’s goals of care, and the treatment target.
The model is designed to help physicians and patients look at the big picture to help decide whether medications are doÂ¬ing more harm than good. A statin may help reduce a patient’s cholesterol, for example, but if that person has trouble tolerating medications and has less than two years to live, is the therapy actually helping?
Dr. Holmes, who is a geriatrician and clinical instructor of medicine at the University of Chicago, has found that her apÂ¬proach can be a tough pill to swallow for physicians. During a recent month-long inpatient rotation, she spent a fair amount of time addressing the misconceptions of several residents on her team who thought that as a rule, she opposed giving the elderly a wide range of medications.
Take the 67-year-old woman with poorly controlled diabetes, a new diagnosis of dementia and a hemoglobin A1C of 13 perÂ¬cent. When a medical student suggested a fasting lipid panel so the patient could begin statin therapy as an outpatient, a resident wondered aloud whether Dr. Holmes would agree. After all, he asked, didn’t her commentary suggest that she was predisposed against giving these drugs to the elderly.
Dr. Holmes says that she explained that according to the model, a statin was in fact an appropriate choice for the woman. While it was true that the patient had poorly controlled diabetes and dementia, she had about 15 years to live. As a result, statins would have more than enough time to do their job and prevent a heart attack or stroke.
Explaining life expectancy
How does Dr. Holmes use the model in her day-to-day practice? For one, she tends to apply it to elderly patients who are near the end of life and taking a plethora of pills. She also tends to shy away from telling her patients how long they have left to live.
“I may say that it seems like you take a lot of medications,” she explains, “that I’m concerned about whether some of them are really benefiting you, especially considering how much they cost and how many side effects you’re having. I almost never speak in raw numbers, unless a patient is very advanced and likely has six months or less to live.”
Dr. Holmes notes that she also tends to discuss life expecÂ¬tancy in broad terms and might say something like the following: “You’re getting to the point that you have so many advanced disÂ¬eases that are severe that we’re talking about how years or months you have left, not years or decades. You haven’t been able to walk for a year. We need to talk about which medications no longer seem like the best choice given how sick you are.”
“I make the comparison that we’re talking about a handful of years vs. many, many years,” Dr. Holmes says.
A role for hospitalists?
Dr. Holmes admits that suggesting patients discontinue one or more medications may be easier for primary care physicians, who have an established relationship with patients. But she adds that hospitalists have an excellent opportunity to help elderly patients reassess their medication regimens precisely because they are new to the patient.
“When a patient is unknown to a physician in the hospital, that’s an opportunity to revisit everything freshly and to avoid what we call clinical inertia,” Dr. Holmes says.” It’s a time when you can openly assess the goals of care with a fresh perspective, not the perspective of someone who has been caring for a patient for five or 10 years and may be very emotionally invested in the person.”
Take the patient who has been admitted for end-stage CHF with exacerbations four or five times in the last six months. SitÂ¬ting down with the patient to talk about life expectancy and goals is not only appropriate, Dr. Homes says, but often welcome by patients.
“What you’re telling them is not news,” she explains. “They know that their disease is advanced and that they’re approaching the end stages.”
There is another complicating factor for hospitalists who help patients decide to discontinue a medication: talking to primary care physicians. Dr. Holmes acknowledges that those conversaÂ¬tions can be delicate, but she says that she’s found that it helps to approach the conversation as a specialist, not a generalist.
“That’s where I put on my I’m-a-geriatrician-and-therefore-a-specialist hat,” she says, “which is something that I think applies to hospitalists. Geriatricians are not super internists who just take care of old people, just like hospitalists are not super internists who want to be residents for the rest of their lives.”
“It’s important to remind the primary care provider that you have unique expertise that helps care for the patient in addition to their care,” Dr. Holmes adds. “It’s not necessarily better than their care, just different.”
What patients think
While physicians may worry that patients will be reluctant to give up a medication, Dr. Holmes thinks that the bigger challenge is changing the minds of physicians, who she says tend to underestiÂ¬mate the willingness of their patients to stop taking medications.
There is little in the way of hard data on patients’ attitudes toÂ¬ward stopping medications, so Dr. Holmes points to the literature on medication adherence to gauge the willingness of patients to stop taking a medication. That literature has consistently found that patients stop taking their medications all the time, and often without talking to their physician first.
Physicians may worry that patients are taking drugs they don’t know about, she notes, but the bigger problem is that patients are prioritizing their medications on their own and stopping them without talking to their physician.
Patients might be discontinuing drugs because of costs, adÂ¬verse effects or other factors, but the point is that they’re willing to stop taking a drug when they think there is a good reason. That should persuade physicians everywhere not only that patients are willing to discontinue medications that aren’t appropriate, but that they as physicians have a golden opportunity to help guide that decision-making process.
“Patients feel like they have to do something,” Dr. Holmes says. “If we’re not going to tell them what we think is best and give our advice and come to an agreement, they’re going to do it without us.”
Edward Doyle is Editor of Today’s Hospitalist.