M. Alexander Otto

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

VANCOUVER, B.C. – Withdrawing medications at the end of life is often the right thing to do clinically, but it can make hospice patients feel abandoned, according to nurse Beverly Lunsford, Ph.D.

"People have it hammered in their heads to take their diabetes medications, their hypertension medications, and have done it faithfully for [decades]. Now you’re telling them to stop. They may have a real sense that isn’t right. Families may perceive medication discontinuation as substandard care or lack of care," said Dr. Lunsford, who coordinates the graduate program for palliative care nurse practitioners at George Washington University in Washington.

It’s important to reassure patients and families that’s not the case or, better yet, handle the situation in such a way that they don’t think so in the first place, Dr. Lunsford said at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

A review with the patient of his or her medications is a good place to start, said Dr. Robert Kaiser, associate geriatrics and palliative care professor at the university. In such "brown-bag reviews," patients bring in every medication they take, including nutritional supplements and other over-the-counter preparations. Clinicians then check whether the drugs’ original indications still apply and ask about side effects and adherence. Most hospice patients need such attention as they typically are on at least five drugs at admission to hospice, with more added for comfort care, Dr. Kaiser said.

Medication issues should also be incorporated into goals-of-care discussions, said Dr. Lunsford. When patients opt for comfort care, "you might sort out with them which medications they are taking for symptom relief and what medications they are taking for treating medical conditions" that are no longer a high priority, such as hypercholesterolemia, she said.

A patient might be more open to this discussion if a clinician points out that the person’s medical condition has changed – that he or she has lost weight, for instance – so certain drugs are less necessary. Once-tolerated doses may be too potent because of loss of kidney or liver function. Difficulty swallowing and memory loss may also make adherence increasingly burdensome, Dr. Kaiser said.

The goal is to cut unneeded medications so side effects, such as falls and confusion, and drug interactions don’t add discomfort to the dying process, he said. Picking which drugs to stop, however, is not an exact science. Life expectancy, how a drug meets care goals, and how long a drug takes to work are among some of the factors to consider.

Dr. Lunsford and Dr. Kaiser recommended several guides to withdrawing drugs at the end of life. The Medication Appropriateness Index, a 10-question tool for gauging appropriate drug use, can help, they said, as can the list of drugs and dosages to avoid in the elderly according to the Beers criteria (Arch. Intern. Med. 2006;166:605-9).

They cited other references making the point that drugs for chronic conditions may reasonably be discontinued. Statins, bisphosphonates, and cholinesterase inhibitors may be stopped in patients with advanced dementia, poor prognoses, or both, they said, and cholinesterase inhibitors and memantine may be discontinuation candidates because the evidence is marginal for their benefit in advanced dementia patients entering hospice or other palliative care (End of Life/Palliative Education Resource Center. Fast Fact and Concept #174 "Dementia Medications in Palliative Care," www.eperc.mcw.edu). Opioids, beta-blockers, clonidine, gabapentin, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants, among others, require tapering, said Dr. Lunsford and Dr. Kaiser, citing a recent study (JAMA 2010;304:1592-601). A drug holiday may be appropriate when there is uncertainty about withdrawing a medication, Dr. Kaiser said.

Dr. Lunsford cautioned that "many health care professionals may not feel they have the time" to decide what drugs to stop, negotiate the issue with the patient, taper doses, and monitor outcomes on subsequent visits. It’s important to do so, however, and to prevent conflict with peers by keeping them in the loop when discontinuing drugs, she said.

"You need to get them on the same page. Get the case manager involved if you’re not in direct contact with these people, or pick up the phone and [let them know] this is what your suggesting," she said.

Neither Dr. Lunsford nor Dr. Kaiser made conflict-of-interest disclosures.

HUNTINGTON BEACH, CALIF. – Retrievable inferior vena cava filters should be removed once the acute risk of pulmonary embolism or deep venous thrombosis has passed, instead of being left in patients indefinitely, according to Dr. John Curci.

Despite the dearth of data about long-term risks, there are reports of filters thrombosing, migrating, fragmenting, and embolizing, with severe complications. Use of the filters has grown in recent years, and currently in U.S. patients, only about half of them are removed when no longer needed, he said (J. Hosp. Med. 2009;4:441-8).

"Should you remove the filters? I think just based on the fact that we don’t have good long-term data, the answer is yes," he said, noting that filter removal is "fast, easy, and billable," with potentially an 85% or better retrieval rate.

About 60 embolizations to the heart have been reported over the past 15 years. Such reports "need to be scaring us all a little bit until we really know what [the risks] are," Dr. Curci said (J. Invasive Cardiol. 2009;21:606-10).

Dr. Curci, a vascular surgeon at Washington University in St. Louis, Mo., made the case for removal of the filters during the meeting.

Early in their development, the filters were placed therapeutically in patients with pulmonary embolisms (PEs) or deep venous thromboses (DVTs) or histories of them.

With the development of retrievable filters, there’s been a shift over the past 15 years to prophylactic placement when the risk of DVT or PE is anticipated to be high, or when there is a risk of bleeding with anticoagulation.

"This has led to a lot of excitement about putting these filters in, and so we are increasing [their] use," Dr. Curci said. However, the risk of fatal or debilitating PEs or DVTs in the absence of any preceding symptoms is low, and usually short-lived.

Because of that, "the safety bar must be [correspondingly] high" for filters meant to prevent them, he said.

It is in that context that rare reports of filter fractures and embolisms become important. In one of the few attempts to assess long-term risks, 80 patients with filters placed between April 2004 and January 2009 were fluoroscoped to assess filter integrity. Filters had fractured and fragmented in 13 patients and embolized in 7, including 5 patients with embolization to the heart.

Three of those five patients experienced life-threatening ventricular tachycardia and/or tamponade. One patient died (Arch. Intern. Med. 2010;170:1827-31).

"That’s not minor, to have a piece of your filter in your heart. We not only have to think about [filter risks] in the short term, but also in the long term" and "whether placement is justified" in the first place, Dr. Curci said.

He said he has no disclosures.

HUNTINGTON BEACH, CALIF. – Retrievable inferior vena cava filters should be removed once the acute risk of pulmonary embolism or deep venous thrombosis has passed, instead of being left in patients indefinitely, according to Dr. John Curci.

Despite the dearth of data about long-term risks, there are reports of filters thrombosing, migrating, fragmenting, and embolizing, with severe complications. Use of the filters has grown in recent years, and currently in U.S. patients, only about half of them are removed when no longer needed, he said (J. Hosp. Med. 2009;4:441-8).

"Should you remove the filters? I think just based on the fact that we don’t have good long-term data, the answer is yes," he said, noting that filter removal is "fast, easy, and billable," with potentially an 85% or better retrieval rate.

About 60 embolizations to the heart have been reported over the past 15 years. Such reports "need to be scaring us all a little bit until we really know what [the risks] are," Dr. Curci said (J. Invasive Cardiol. 2009;21:606-10).

Dr. Curci, a vascular surgeon at Washington University in St. Louis, Mo., made the case for removal of the filters during the meeting.

Early in their development, the filters were placed therapeutically in patients with pulmonary embolisms (PEs) or deep venous thromboses (DVTs) or histories of them.

With the development of retrievable filters, there’s been a shift over the past 15 years to prophylactic placement when the risk of DVT or PE is anticipated to be high, or when there is a risk of bleeding with anticoagulation.

"This has led to a lot of excitement about putting these filters in, and so we are increasing [their] use," Dr. Curci said. However, the risk of fatal or debilitating PEs or DVTs in the absence of any preceding symptoms is low, and usually short-lived.

Because of that, "the safety bar must be [correspondingly] high" for filters meant to prevent them, he said.

It is in that context that rare reports of filter fractures and embolisms become important. In one of the few attempts to assess long-term risks, 80 patients with filters placed between April 2004 and January 2009 were fluoroscoped to assess filter integrity. Filters had fractured and fragmented in 13 patients and embolized in 7, including 5 patients with embolization to the heart.

Three of those five patients experienced life-threatening ventricular tachycardia and/or tamponade. One patient died (Arch. Intern. Med. 2010;170:1827-31).

"That’s not minor, to have a piece of your filter in your heart. We not only have to think about [filter risks] in the short term, but also in the long term" and "whether placement is justified" in the first place, Dr. Curci said.

He said he has no disclosures.

HUNTINGTON BEACH, CALIF. – Retrievable inferior vena cava filters should be removed once the acute risk of pulmonary embolism or deep venous thrombosis has passed, instead of being left in patients indefinitely, according to Dr. John Curci.

Despite the dearth of data about long-term risks, there are reports of filters thrombosing, migrating, fragmenting, and embolizing, with severe complications. Use of the filters has grown in recent years, and currently in U.S. patients, only about half of them are removed when no longer needed, he said (J. Hosp. Med. 2009;4:441-8).

"Should you remove the filters? I think just based on the fact that we don’t have good long-term data, the answer is yes," he said, noting that filter removal is "fast, easy, and billable," with potentially an 85% or better retrieval rate.

About 60 embolizations to the heart have been reported over the past 15 years. Such reports "need to be scaring us all a little bit until we really know what [the risks] are," Dr. Curci said (J. Invasive Cardiol. 2009;21:606-10).

Dr. Curci, a vascular surgeon at Washington University in St. Louis, Mo., made the case for removal of the filters during the meeting.

Early in their development, the filters were placed therapeutically in patients with pulmonary embolisms (PEs) or deep venous thromboses (DVTs) or histories of them.

With the development of retrievable filters, there’s been a shift over the past 15 years to prophylactic placement when the risk of DVT or PE is anticipated to be high, or when there is a risk of bleeding with anticoagulation.

"This has led to a lot of excitement about putting these filters in, and so we are increasing [their] use," Dr. Curci said. However, the risk of fatal or debilitating PEs or DVTs in the absence of any preceding symptoms is low, and usually short-lived.

Because of that, "the safety bar must be [correspondingly] high" for filters meant to prevent them, he said.

It is in that context that rare reports of filter fractures and embolisms become important. In one of the few attempts to assess long-term risks, 80 patients with filters placed between April 2004 and January 2009 were fluoroscoped to assess filter integrity. Filters had fractured and fragmented in 13 patients and embolized in 7, including 5 patients with embolization to the heart.

Three of those five patients experienced life-threatening ventricular tachycardia and/or tamponade. One patient died (Arch. Intern. Med. 2010;170:1827-31).

"That’s not minor, to have a piece of your filter in your heart. We not only have to think about [filter risks] in the short term, but also in the long term" and "whether placement is justified" in the first place, Dr. Curci said.

He said he has no disclosures.

HUNTINGTON BEACH, CALIF. – Patients with recently placed coronary stents who are on clopidogrel to prevent stent thrombosis may need to discontinue the drug to prevent excessive bleeding during surgery, but it should be restarted as soon as possible, according to Dr. Alan Dardik.

Continuing antiplatelet therapy during the perioperative period is crucial, he noted, because "the risk of surgical bleeding, if dual-antiplatelet therapy is continued, is actually lower than the risk of coronary thrombosis due to agent withdrawal" (Intern. Emerg. Med. 2009;4:279-88).

Antiplatelet drugs pose a considerable bleeding risk: Aspirin can increase surgical blood loss up to 20%, and dual therapy up to 50%. According to Dr. Dardik, however, although "many studies show a small increase in complications from this bleeding, particularly increased transfusions, no study has actually shown an increase in mortality."

Meanwhile, the risk of a fatal myocardial infarction is high when antiplatelet therapy is withdrawn, especially within 6 weeks of stent placement. The risk is especially high in patients with cancer, diabetes, and other hypercoagulable states, and in those with long, multiple, or overlapping stents, Dr. Dardik said (Circulation 2007;116:745-54).

"Keep the nontherapeutic window short, from about 3 days before the surgery to 1 to 2 days afterwards, [and] reload [patients] at high risk for thrombosis with 300 mg of clopidogrel," Dr. Dardik said at the annual Academic Surgical Congress.

Since dual-antiplatelet therapy is standard for 6 months following stent placement, patients on clopidogrel (Plavix) will almost certainly also be on aspirin. To offset the temporary loss of clopidogrel, he recommended increasing the aspirin dose. If patients must come off aspirin, too, "reintroduce [it] the day after surgery," said Dr. Dardik, a vascular surgeon at Yale University, New Haven, Conn.

The best option for recently stented patients is to postpone surgery for at least 6 months – the point at which dual-antiplatelet therapy can be discontinued – or even a year, when aspirin can also be stopped.

When that’s not possible, Dr. Dardik recommends performing a less invasive procedure, with easier hemostasis.

In addition, "work with your [general practitioner], your cardiologist, and your anesthesiologist to evaluate the risk of bleeding versus thrombosis," Dr. Dardik said.

If it is known that a patient who is planned for a stent will need surgery within a year, he also suggested considering whether angioplasty alone or some other therapeutic intervention might be appropriate.

At this point, bare-metal and drug-eluting stents appear to carry similar thrombosis risks, Dr. Dardik noted.

He said he has no relevant disclosures.

HUNTINGTON BEACH, CALIF. – Patients with recently placed coronary stents who are on clopidogrel to prevent stent thrombosis may need to discontinue the drug to prevent excessive bleeding during surgery, but it should be restarted as soon as possible, according to Dr. Alan Dardik.

Continuing antiplatelet therapy during the perioperative period is crucial, he noted, because "the risk of surgical bleeding, if dual-antiplatelet therapy is continued, is actually lower than the risk of coronary thrombosis due to agent withdrawal" (Intern. Emerg. Med. 2009;4:279-88).

Antiplatelet drugs pose a considerable bleeding risk: Aspirin can increase surgical blood loss up to 20%, and dual therapy up to 50%. According to Dr. Dardik, however, although "many studies show a small increase in complications from this bleeding, particularly increased transfusions, no study has actually shown an increase in mortality."

Meanwhile, the risk of a fatal myocardial infarction is high when antiplatelet therapy is withdrawn, especially within 6 weeks of stent placement. The risk is especially high in patients with cancer, diabetes, and other hypercoagulable states, and in those with long, multiple, or overlapping stents, Dr. Dardik said (Circulation 2007;116:745-54).

"Keep the nontherapeutic window short, from about 3 days before the surgery to 1 to 2 days afterwards, [and] reload [patients] at high risk for thrombosis with 300 mg of clopidogrel," Dr. Dardik said at the annual Academic Surgical Congress.

Since dual-antiplatelet therapy is standard for 6 months following stent placement, patients on clopidogrel (Plavix) will almost certainly also be on aspirin. To offset the temporary loss of clopidogrel, he recommended increasing the aspirin dose. If patients must come off aspirin, too, "reintroduce [it] the day after surgery," said Dr. Dardik, a vascular surgeon at Yale University, New Haven, Conn.

The best option for recently stented patients is to postpone surgery for at least 6 months – the point at which dual-antiplatelet therapy can be discontinued – or even a year, when aspirin can also be stopped.

When that’s not possible, Dr. Dardik recommends performing a less invasive procedure, with easier hemostasis.

In addition, "work with your [general practitioner], your cardiologist, and your anesthesiologist to evaluate the risk of bleeding versus thrombosis," Dr. Dardik said.

If it is known that a patient who is planned for a stent will need surgery within a year, he also suggested considering whether angioplasty alone or some other therapeutic intervention might be appropriate.

At this point, bare-metal and drug-eluting stents appear to carry similar thrombosis risks, Dr. Dardik noted.

He said he has no relevant disclosures.

HUNTINGTON BEACH, CALIF. – Patients with recently placed coronary stents who are on clopidogrel to prevent stent thrombosis may need to discontinue the drug to prevent excessive bleeding during surgery, but it should be restarted as soon as possible, according to Dr. Alan Dardik.

Continuing antiplatelet therapy during the perioperative period is crucial, he noted, because "the risk of surgical bleeding, if dual-antiplatelet therapy is continued, is actually lower than the risk of coronary thrombosis due to agent withdrawal" (Intern. Emerg. Med. 2009;4:279-88).

Antiplatelet drugs pose a considerable bleeding risk: Aspirin can increase surgical blood loss up to 20%, and dual therapy up to 50%. According to Dr. Dardik, however, although "many studies show a small increase in complications from this bleeding, particularly increased transfusions, no study has actually shown an increase in mortality."

Meanwhile, the risk of a fatal myocardial infarction is high when antiplatelet therapy is withdrawn, especially within 6 weeks of stent placement. The risk is especially high in patients with cancer, diabetes, and other hypercoagulable states, and in those with long, multiple, or overlapping stents, Dr. Dardik said (Circulation 2007;116:745-54).

"Keep the nontherapeutic window short, from about 3 days before the surgery to 1 to 2 days afterwards, [and] reload [patients] at high risk for thrombosis with 300 mg of clopidogrel," Dr. Dardik said at the annual Academic Surgical Congress.

Since dual-antiplatelet therapy is standard for 6 months following stent placement, patients on clopidogrel (Plavix) will almost certainly also be on aspirin. To offset the temporary loss of clopidogrel, he recommended increasing the aspirin dose. If patients must come off aspirin, too, "reintroduce [it] the day after surgery," said Dr. Dardik, a vascular surgeon at Yale University, New Haven, Conn.

The best option for recently stented patients is to postpone surgery for at least 6 months – the point at which dual-antiplatelet therapy can be discontinued – or even a year, when aspirin can also be stopped.

When that’s not possible, Dr. Dardik recommends performing a less invasive procedure, with easier hemostasis.

In addition, "work with your [general practitioner], your cardiologist, and your anesthesiologist to evaluate the risk of bleeding versus thrombosis," Dr. Dardik said.

If it is known that a patient who is planned for a stent will need surgery within a year, he also suggested considering whether angioplasty alone or some other therapeutic intervention might be appropriate.

At this point, bare-metal and drug-eluting stents appear to carry similar thrombosis risks, Dr. Dardik noted.

He said he has no relevant disclosures.

HUNTINGTON BEACH, CALIF. – Patients with recently placed coronary stents who are on clopidogrel to prevent stent thrombosis may need to discontinue the drug to prevent excessive bleeding during surgery, but it should be restarted as soon as possible, according to Dr. Alan Dardik.

Continuing antiplatelet therapy during the perioperative period is crucial, he noted, because "the risk of surgical bleeding, if dual-antiplatelet therapy is continued, is actually lower than the risk of coronary thrombosis due to agent withdrawal" (Intern. Emerg. Med. 2009;4:279-88).

Antiplatelet drugs pose a considerable bleeding risk: Aspirin can increase surgical blood loss up to 20%, and dual therapy up to 50%. According to Dr. Dardik, however, although "many studies show a small increase in complications from this bleeding, particularly increased transfusions, no study has actually shown an increase in mortality."

Meanwhile, the risk of a fatal myocardial infarction is high when antiplatelet therapy is withdrawn, especially within 6 weeks of stent placement. The risk is especially high in patients with cancer, diabetes, and other hypercoagulable states, and in those with long, multiple, or overlapping stents, Dr. Dardik said (Circulation 2007;116:745-54).

"Keep the nontherapeutic window short, from about 3 days before the surgery to 1 to 2 days afterwards, [and] reload [patients] at high risk for thrombosis with 300 mg of clopidogrel," Dr. Dardik said at the annual Academic Surgical Congress.

Since dual-antiplatelet therapy is standard for 6 months following stent placement, patients on clopidogrel (Plavix) will almost certainly also be on aspirin. To offset the temporary loss of clopidogrel, he recommended increasing the aspirin dose. If patients must come off aspirin, too, "reintroduce [it] the day after surgery," said Dr. Dardik, a vascular surgeon at Yale University, New Haven, Conn.

The best option for recently stented patients is to postpone surgery for at least 6 months – the point at which dual-antiplatelet therapy can be discontinued – or even a year, when aspirin can also be stopped.

When that’s not possible, Dr. Dardik recommends performing a less invasive procedure, with easier hemostasis.

In addition, "work with your [general practitioner], your cardiologist, and your anesthesiologist to evaluate the risk of bleeding versus thrombosis," Dr. Dardik said.

If it is known that a patient who is planned for a stent will need surgery within a year, he also suggested considering whether angioplasty alone or some other therapeutic intervention might be appropriate.

At this point, bare-metal and drug-eluting stents appear to carry similar thrombosis risks, Dr. Dardik noted.

He said he has no relevant disclosures.

HUNTINGTON BEACH, CALIF. – Patients with recently placed coronary stents who are on clopidogrel to prevent stent thrombosis may need to discontinue the drug to prevent excessive bleeding during surgery, but it should be restarted as soon as possible, according to Dr. Alan Dardik.

Continuing antiplatelet therapy during the perioperative period is crucial, he noted, because "the risk of surgical bleeding, if dual-antiplatelet therapy is continued, is actually lower than the risk of coronary thrombosis due to agent withdrawal" (Intern. Emerg. Med. 2009;4:279-88).

Antiplatelet drugs pose a considerable bleeding risk: Aspirin can increase surgical blood loss up to 20%, and dual therapy up to 50%. According to Dr. Dardik, however, although "many studies show a small increase in complications from this bleeding, particularly increased transfusions, no study has actually shown an increase in mortality."

Meanwhile, the risk of a fatal myocardial infarction is high when antiplatelet therapy is withdrawn, especially within 6 weeks of stent placement. The risk is especially high in patients with cancer, diabetes, and other hypercoagulable states, and in those with long, multiple, or overlapping stents, Dr. Dardik said (Circulation 2007;116:745-54).

"Keep the nontherapeutic window short, from about 3 days before the surgery to 1 to 2 days afterwards, [and] reload [patients] at high risk for thrombosis with 300 mg of clopidogrel," Dr. Dardik said at the annual Academic Surgical Congress.

Since dual-antiplatelet therapy is standard for 6 months following stent placement, patients on clopidogrel (Plavix) will almost certainly also be on aspirin. To offset the temporary loss of clopidogrel, he recommended increasing the aspirin dose. If patients must come off aspirin, too, "reintroduce [it] the day after surgery," said Dr. Dardik, a vascular surgeon at Yale University, New Haven, Conn.

The best option for recently stented patients is to postpone surgery for at least 6 months – the point at which dual-antiplatelet therapy can be discontinued – or even a year, when aspirin can also be stopped.

When that’s not possible, Dr. Dardik recommends performing a less invasive procedure, with easier hemostasis.

In addition, "work with your [general practitioner], your cardiologist, and your anesthesiologist to evaluate the risk of bleeding versus thrombosis," Dr. Dardik said.

If it is known that a patient who is planned for a stent will need surgery within a year, he also suggested considering whether angioplasty alone or some other therapeutic intervention might be appropriate.

At this point, bare-metal and drug-eluting stents appear to carry similar thrombosis risks, Dr. Dardik noted.

He said he has no relevant disclosures.

HUNTINGTON BEACH, CALIF. – Patients with recently placed coronary stents who are on clopidogrel to prevent stent thrombosis may need to discontinue the drug to prevent excessive bleeding during surgery, but it should be restarted as soon as possible, according to Dr. Alan Dardik.

Continuing antiplatelet therapy during the perioperative period is crucial, he noted, because "the risk of surgical bleeding, if dual-antiplatelet therapy is continued, is actually lower than the risk of coronary thrombosis due to agent withdrawal" (Intern. Emerg. Med. 2009;4:279-88).

Antiplatelet drugs pose a considerable bleeding risk: Aspirin can increase surgical blood loss up to 20%, and dual therapy up to 50%. According to Dr. Dardik, however, although "many studies show a small increase in complications from this bleeding, particularly increased transfusions, no study has actually shown an increase in mortality."

Meanwhile, the risk of a fatal myocardial infarction is high when antiplatelet therapy is withdrawn, especially within 6 weeks of stent placement. The risk is especially high in patients with cancer, diabetes, and other hypercoagulable states, and in those with long, multiple, or overlapping stents, Dr. Dardik said (Circulation 2007;116:745-54).

"Keep the nontherapeutic window short, from about 3 days before the surgery to 1 to 2 days afterwards, [and] reload [patients] at high risk for thrombosis with 300 mg of clopidogrel," Dr. Dardik said at the annual Academic Surgical Congress.

Since dual-antiplatelet therapy is standard for 6 months following stent placement, patients on clopidogrel (Plavix) will almost certainly also be on aspirin. To offset the temporary loss of clopidogrel, he recommended increasing the aspirin dose. If patients must come off aspirin, too, "reintroduce [it] the day after surgery," said Dr. Dardik, a vascular surgeon at Yale University, New Haven, Conn.

The best option for recently stented patients is to postpone surgery for at least 6 months – the point at which dual-antiplatelet therapy can be discontinued – or even a year, when aspirin can also be stopped.

When that’s not possible, Dr. Dardik recommends performing a less invasive procedure, with easier hemostasis.

In addition, "work with your [general practitioner], your cardiologist, and your anesthesiologist to evaluate the risk of bleeding versus thrombosis," Dr. Dardik said.

If it is known that a patient who is planned for a stent will need surgery within a year, he also suggested considering whether angioplasty alone or some other therapeutic intervention might be appropriate.

At this point, bare-metal and drug-eluting stents appear to carry similar thrombosis risks, Dr. Dardik noted.

He said he has no relevant disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. – Within a year of implementation, mandatory palliative care screening significantly increased palliative care consults at St. John Hospital and Medical Center in Detroit.

The increased use of palliative care services saved the hospital about $700,000 in fiscal year 2008, because of shorter lengths of stay and patients opting for less-heroic care, among other factors.

As a result, St. John Providence Health System now screens patients admitted to St. John and its other four hospitals for palliative care needs, and is incorporating screening into its electronic health record (EHR) system, said nurse Elizabeth DiStefano, the system’s palliative care coordinator.

Planning for the screening program started in 2006 after hospital administrators realized that not all eligible patients were referred for palliative care consults at the five hospitals.

They decided to test-pilot mandatory screening at St. John to see if it would help, collaborating on the project with the Duke Institute on Care at the End of Life, Durham, N.C. The goal was to "increase access to palliative care," Ms. DiStefano said.

A multidisciplinary working group developed a two-page screening checklist and tested it in St. John’s 20-bed medical intensive care unit, an oncology unit, and two medical units, starting in April 2007.

After a year, they streamlined the checklist down to nine items, any one of which triggered a consult.

Mandatory screening had a significant impact. In 2006, before it was implemented, there were 444 palliative care consults; the number increased to 742 in 2007 and to 952 in 2008. The time from admission to consult dropped from about 9 days to about 6.

The success led to a systemwide rollout of palliative care screening, with the nine triggers now assessed in patients admitted to the health system’s five hospitals.

The nine triggers are:

• Code status changed to "do not resuscitate."

• Conflict about starting or stopping life-prolonging treatment.

• Discussion about goals of care or code status, and/or surrogate distress about decision making.

• A marked decrease in functional status within 2 months.

• Uncontrolled symptoms, such as pain or nausea, interfering with quality of life.

• Consideration of percutaneous endoscopic gastronomy tube placement.

• Admission from an extended-care facility with dependence for activities of daily living.

• Nonambulatory dementia with no speech, or with recurrent aspiration pneumonia.

• A patient or family request for palliative care.

The screening "identifies patients further upstream" who need services, "so it isn’t just end-of-life patients," Ms. DiStefano said.

Palliative care staffing varies at the hospitals based on size. At the 650-bed St. John Hospital, two nurse practitioners, a physician, a medical social worker, and a chaplain help with symptom management, discharge planning, advance directives, and other issues, such as spiritual and emotional needs.

Both patients and families "appreciate there’s a team effort [that looks after] the whole family, putting the whole picture together" to improve quality of life, Ms. DiStefano said.

Palliative care is cash-flow positive as well, with the savings covering the costs, and then some.

But for such a program to work, palliative care screening must be easily incorporated into existing procedures, she said.

For that reason, a mandatory field is being added to her health system’s EHR system that requires nurses to assess the nine triggers at admission, then again 5 days later. When a patient screens positive, the system sends an alert to the attending physician’s e-mail in-box asking for a palliative care referral order.

With the paper system, the triggers are assessed only at admission, and nurses call attendings when patients screen positive, she said.

Some physicians resisted palliative care during the pilot, thinking they could do a better job tending to patients’ needs themselves, or mistaking palliative care for hospice care.

One ICU doctor was reluctant to call in the palliative care team for a young patient. When asked why, he said he thought the 20-year-old patient was too young for hospice, Ms. DiStefano said.

When she explained that the team would talk to the patient and family about symptom control and quality of life, the physician became one of the team’s biggest supporters, Ms. DiStefano said.

The pilot was funded by local foundations and hospital administrators. Ms. DiStefano said she had no financial disclosures.

VANCOUVER, B.C. - People with implanted cardioverter defibrillators should be given the option of having the devices deactivated when they enter hospice care, Dr. Bernard Lee told his audience at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

When avoidance of sudden death is no longer the goal, deactivation of the devices to prevent shocking patients as their hearts fail "is ethically the right thing to do," said Dr. Lee, associate chief medical officer of hospice and palliative care at the Metropolitan Jewish Health System in Brooklyn, N.Y.

Although the issue has gotten some attention in recent years, research has shown that fewer than half of implanted cardioverter defibrillators (ICDs) are deactivated in hospice patients, said Dr. Lee (Ann. Intern. Med. 2010;152:296-9).

"We are not really doing a good job," said Dr. Michael Mencias, also of Metropolitan Jewish Health System. Even if the patient is unconscious and can’t feel the painful jolts, his or her body will jerk with each shock, alarming family members and making them feel that they didn’t make the patient’s final hours as comfortable as possible.

Often, patients and families – sometimes even providers – don’t know that ICDs can be painlessly deactivated magnetically and that doing so may prevent havoc at the end of life. And not infrequently, families have the mistaken impression that deactivation equals euthanasia or physician-assisted suicide, said Dr. Lee and Dr. Mencias.

Pacing Function Left Active

Palliative care and hospice clinicians can do better, the speakers said. A position statement from the National Organization of Hospice and Palliative Care gives tips on how to handle the issue (www.nhpco.org/files/public/NHPCO_ICD_position_statement_May08.pdf). In short, the group recommends asking all patients or families at hospice admission (or as soon as possible) whether a defibrillator has been implanted.

The group says that a health professional should then explain the potential problems if an ICD is not deactivated, and that deactivation is not likely to hasten death. When a patient has decided whether to keep the device turned on, everyone on the medical team should be so informed, says the statement.

The ICD’s detection of ventricular tachycardia or fibrillation – the function that tells the device to fire – can be deactivated either by a manufacturer’s technician or (less permanently) by a medical professional who can secure a magnet over the device. Available from ICD makers, the magnets are strong and measure a few inches across. They deactivate the sensing function, but that function returns if the magnet is removed.

When a patient’s time is short, Dr. Lee said he tries to quickly pull together a family meeting to discuss deactivation. "In worst-case scenarios, it’s done over the phone with the hospice physician and the patient or health care surrogate," he added.

For hospice patients at home, a magnet can be left with the family, with instructions on how to tape it to the chest to stop body-jolting shocks. Home-visiting nurses in Dr. Lee’s organization carry magnets in their cars in case a patient who is dying at home needs one quickly.

The application of magnets to a patient’s chest, however, is "certainly not a long-term solution for somebody who’s not actively dying," Dr. Lee said. Especially for frail patients who have lost weight, a magnet taped to the chest is uncomfortable, he added.

Deactivation Hesitation

Dr. Lee said that his organization broaches the topic of deactivation within 5 days of a patient’s admission to hospice. If the person opts for deactivation, the device’s manufacturer is called.

Often patients will have lost the card that came with their ICD, said Dr. Lee, so it’s necessary to call the various manufacturers – typically Medtronics, Guidant/Boston Scientific, and St. Jude Medical – to find out what device the patient carries. The companies will have a record.

Technicians will make house calls, if necessary, to deactivate an ICD’s sensing function in the presence of a licensed medical professional, and they can return to reactivate it if the patient changes his or her mind.

Deactivation usually requires a hospice physician’s order, said Dr. Lee. "Most physicians in the community are not comfortable writing that order."

Technicians themselves may even hesitate to deactivate an ICD. "Some of them are uncomfortable, so they will hand you the laptop and say ‘here, click on deactivate.’ We end up doing it," Dr. Mencias said.

Dr. Lee and Dr. Mencias said they have no conflict of interest.

VANCOUVER, B.C. - People with implanted cardioverter defibrillators should be given the option of having the devices deactivated when they enter hospice care, Dr. Bernard Lee told his audience at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

When avoidance of sudden death is no longer the goal, deactivation of the devices to prevent shocking patients as their hearts fail "is ethically the right thing to do," said Dr. Lee, associate chief medical officer of hospice and palliative care at the Metropolitan Jewish Health System in Brooklyn, N.Y.

Although the issue has gotten some attention in recent years, research has shown that fewer than half of implanted cardioverter defibrillators (ICDs) are deactivated in hospice patients, said Dr. Lee (Ann. Intern. Med. 2010;152:296-9).

"We are not really doing a good job," said Dr. Michael Mencias, also of Metropolitan Jewish Health System. Even if the patient is unconscious and can’t feel the painful jolts, his or her body will jerk with each shock, alarming family members and making them feel that they didn’t make the patient’s final hours as comfortable as possible.

Often, patients and families – sometimes even providers – don’t know that ICDs can be painlessly deactivated magnetically and that doing so may prevent havoc at the end of life. And not infrequently, families have the mistaken impression that deactivation equals euthanasia or physician-assisted suicide, said Dr. Lee and Dr. Mencias.

Pacing Function Left Active

Palliative care and hospice clinicians can do better, the speakers said. A position statement from the National Organization of Hospice and Palliative Care gives tips on how to handle the issue (www.nhpco.org/files/public/NHPCO_ICD_position_statement_May08.pdf). In short, the group recommends asking all patients or families at hospice admission (or as soon as possible) whether a defibrillator has been implanted.

The group says that a health professional should then explain the potential problems if an ICD is not deactivated, and that deactivation is not likely to hasten death. When a patient has decided whether to keep the device turned on, everyone on the medical team should be so informed, says the statement.

The ICD’s detection of ventricular tachycardia or fibrillation – the function that tells the device to fire – can be deactivated either by a manufacturer’s technician or (less permanently) by a medical professional who can secure a magnet over the device. Available from ICD makers, the magnets are strong and measure a few inches across. They deactivate the sensing function, but that function returns if the magnet is removed.

When a patient’s time is short, Dr. Lee said he tries to quickly pull together a family meeting to discuss deactivation. "In worst-case scenarios, it’s done over the phone with the hospice physician and the patient or health care surrogate," he added.

For hospice patients at home, a magnet can be left with the family, with instructions on how to tape it to the chest to stop body-jolting shocks. Home-visiting nurses in Dr. Lee’s organization carry magnets in their cars in case a patient who is dying at home needs one quickly.

The application of magnets to a patient’s chest, however, is "certainly not a long-term solution for somebody who’s not actively dying," Dr. Lee said. Especially for frail patients who have lost weight, a magnet taped to the chest is uncomfortable, he added.

Deactivation Hesitation

Dr. Lee said that his organization broaches the topic of deactivation within 5 days of a patient’s admission to hospice. If the person opts for deactivation, the device’s manufacturer is called.

Often patients will have lost the card that came with their ICD, said Dr. Lee, so it’s necessary to call the various manufacturers – typically Medtronics, Guidant/Boston Scientific, and St. Jude Medical – to find out what device the patient carries. The companies will have a record.

Technicians will make house calls, if necessary, to deactivate an ICD’s sensing function in the presence of a licensed medical professional, and they can return to reactivate it if the patient changes his or her mind.

Deactivation usually requires a hospice physician’s order, said Dr. Lee. "Most physicians in the community are not comfortable writing that order."

Technicians themselves may even hesitate to deactivate an ICD. "Some of them are uncomfortable, so they will hand you the laptop and say ‘here, click on deactivate.’ We end up doing it," Dr. Mencias said.

Dr. Lee and Dr. Mencias said they have no conflict of interest.

VANCOUVER, B.C. - People with implanted cardioverter defibrillators should be given the option of having the devices deactivated when they enter hospice care, Dr. Bernard Lee told his audience at the annual meeting of the American Academy of Hospice and Palliative Care Medicine.

When avoidance of sudden death is no longer the goal, deactivation of the devices to prevent shocking patients as their hearts fail "is ethically the right thing to do," said Dr. Lee, associate chief medical officer of hospice and palliative care at the Metropolitan Jewish Health System in Brooklyn, N.Y.

Although the issue has gotten some attention in recent years, research has shown that fewer than half of implanted cardioverter defibrillators (ICDs) are deactivated in hospice patients, said Dr. Lee (Ann. Intern. Med. 2010;152:296-9).

"We are not really doing a good job," said Dr. Michael Mencias, also of Metropolitan Jewish Health System. Even if the patient is unconscious and can’t feel the painful jolts, his or her body will jerk with each shock, alarming family members and making them feel that they didn’t make the patient’s final hours as comfortable as possible.

Often, patients and families – sometimes even providers – don’t know that ICDs can be painlessly deactivated magnetically and that doing so may prevent havoc at the end of life. And not infrequently, families have the mistaken impression that deactivation equals euthanasia or physician-assisted suicide, said Dr. Lee and Dr. Mencias.

Pacing Function Left Active

Palliative care and hospice clinicians can do better, the speakers said. A position statement from the National Organization of Hospice and Palliative Care gives tips on how to handle the issue (www.nhpco.org/files/public/NHPCO_ICD_position_statement_May08.pdf). In short, the group recommends asking all patients or families at hospice admission (or as soon as possible) whether a defibrillator has been implanted.

The group says that a health professional should then explain the potential problems if an ICD is not deactivated, and that deactivation is not likely to hasten death. When a patient has decided whether to keep the device turned on, everyone on the medical team should be so informed, says the statement.

The ICD’s detection of ventricular tachycardia or fibrillation – the function that tells the device to fire – can be deactivated either by a manufacturer’s technician or (less permanently) by a medical professional who can secure a magnet over the device. Available from ICD makers, the magnets are strong and measure a few inches across. They deactivate the sensing function, but that function returns if the magnet is removed.

When a patient’s time is short, Dr. Lee said he tries to quickly pull together a family meeting to discuss deactivation. "In worst-case scenarios, it’s done over the phone with the hospice physician and the patient or health care surrogate," he added.

For hospice patients at home, a magnet can be left with the family, with instructions on how to tape it to the chest to stop body-jolting shocks. Home-visiting nurses in Dr. Lee’s organization carry magnets in their cars in case a patient who is dying at home needs one quickly.

The application of magnets to a patient’s chest, however, is "certainly not a long-term solution for somebody who’s not actively dying," Dr. Lee said. Especially for frail patients who have lost weight, a magnet taped to the chest is uncomfortable, he added.

Deactivation Hesitation

Dr. Lee said that his organization broaches the topic of deactivation within 5 days of a patient’s admission to hospice. If the person opts for deactivation, the device’s manufacturer is called.

Often patients will have lost the card that came with their ICD, said Dr. Lee, so it’s necessary to call the various manufacturers – typically Medtronics, Guidant/Boston Scientific, and St. Jude Medical – to find out what device the patient carries. The companies will have a record.

Technicians will make house calls, if necessary, to deactivate an ICD’s sensing function in the presence of a licensed medical professional, and they can return to reactivate it if the patient changes his or her mind.

Deactivation usually requires a hospice physician’s order, said Dr. Lee. "Most physicians in the community are not comfortable writing that order."

Technicians themselves may even hesitate to deactivate an ICD. "Some of them are uncomfortable, so they will hand you the laptop and say ‘here, click on deactivate.’ We end up doing it," Dr. Mencias said.

Dr. Lee and Dr. Mencias said they have no conflict of interest.