Supportive Care in Cancer

, Volume 21, Issue 4, pp 1003–1011

Variation in medication use in cancer patients at the end of life: a cross-sectional analysis

  • N. J. H. Raijmakers
  • L. van Zuylen
  • C. J. Furst
  • M. Beccaro
  • L. Maiorana
  • P. Pilastri
  • C. Rossi
  • G. Flego
  • A. van der Heide
  • M. Costantini
Original Article

Abstract

Purpose

Despite advances in cancer treatment, patients still die with unnecessary suffering. Therefore, high-quality end-of-life care is needed. Variations in medication use at the end of life may suggest areas for improvement. This study aims to describe the use of medications during the last days of life of cancer patients and to explore the possibility of using it as a quality measure.

Methods

We conducted an international survey on experts’ opinions regarding potentially inappropriate medications for dying patients. Subsequently, a chart review of deceased cancer patients was conducted, which assessed the current medication use in different settings.

Results

The mean number of medications used in the last 3 days of life was 4.8 (SD 2.1). Hospital patients were less likely than hospice patients to receive opioids, midazolam, haloperidol, and drugs for pulmonary secretions or nausea/vomiting. Over 90 % of experts rated 12 medications as unlikely to be appropriate. Hospital patients were more likely than hospice patients to receive these potentially inappropriate medications. Before the implementation of an end-of-life care pathway, hospital patients had a higher probability, than after, to receive potentially inappropriate medication. Moreover, after implementation of such pathway, patients for whom a pathway was not used were more likely to receive potentially inappropriate medications than patients for whom it was used.

Conclusion

Medication use at the end of life varies widely by setting, both for potentially appropriate and inappropriate medications. Combining experts’ opinion and current medication use resulted in the identification of 16 medications that might be used to assess the quality of cancer care at the end of life.

Keywords

Drug use Drug therapy Expert consultation Palliative care Terminal care Quality indicator 

References

  1. 1.
    Ferlay J, Parkin DM, Steliarova-Foucher E (2010) Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer 46:765–781PubMedCrossRefGoogle Scholar
  2. 2.
    Seow H, Barbera L, Sutradhar R, Howell D, Dudgeon D, Atzema C, Liu Y, Husain A, Sussman J, Earle C (2011) Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol 29:1151–1158PubMedCrossRefGoogle Scholar
  3. 3.
    Aabom B, Kragstrup J, Vondeling H, Bakketeig LS, Stovring H (2005) Defining cancer patients as being in the terminal phase: who receives a formal diagnosis, and what are the effects? J Clin Oncol 23:7411–7416PubMedCrossRefGoogle Scholar
  4. 4.
    Connors FA Jr et al (1995) A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 274:1591–1598CrossRefGoogle Scholar
  5. 5.
    Ellershaw J, Wilkinson S (2011) Care for the dying: a pathway to excellence. University Press, OxfordGoogle Scholar
  6. 6.
    Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, Hull JG, Li Z, Tosteson TD, Byock IR, Ahles TA (2009) Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 302:741–749PubMedCrossRefGoogle Scholar
  7. 7.
    Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733–742PubMedCrossRefGoogle Scholar
  8. 8.
    Gelfman LP, Meier DE, Morrison RS (2008) Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage 36:22–28PubMedCrossRefGoogle Scholar
  9. 9.
    Higginson IJ, Finlay I, Goodwin DM, Cook AM, Hood K, Edwards AG, Douglas HR, Norman CE (2002) Do hospital-based palliative teams improve care for patients or families at the end of life? J Pain Symptom Manage 23:96–106PubMedCrossRefGoogle Scholar
  10. 10.
    Veerbeek L, van Zuylen L, Swart SJ, van der Maas PJ, de Vogel-Voogt E, van der Rijt CC, van der Heide A (2008) The effect of the Liverpool Care Pathway for the dying: a multi-centre study. Palliat Med 22:145–151PubMedCrossRefGoogle Scholar
  11. 11.
    Pugh EJ, McEvoy M, Blenkinsopp J (2010) Use of the proportion of patients dying on an end of life pathway as a quality marker: considerations for interpretation. Palliat Med 24:544–547PubMedCrossRefGoogle Scholar
  12. 12.
    Raijmakers N, Galushko M, Domeisen F, Beccaro M, Lundh Hagelin C, Lindqvist O, Popa-Velea O, Romotzky V, Schuler S, Ellershaw J, Ostgathe C, On Behalf Of Opcare C (2012) Quality indicators for care of cancer patients in their last days of life: literature update and experts’ evaluation. J Palliat Med 15:308–316PubMedGoogle Scholar
  13. 13.
    Iezzoni LI (1997) Assessing quality using administrative data. Ann Intern Med 127:666–674PubMedGoogle Scholar
  14. 14.
    Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S (2003) Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 21:1133–1138PubMedCrossRefGoogle Scholar
  15. 15.
    Grunfeld E, Lethbridge L, Dewar R, Lawson B, Paszat LF, Johnston G, Burge F, McIntyre P, Earle CC (2006) Towards using administrative databases to measure population-based indicators of quality of end-of-life care: testing the methodology. Palliat Med 20:769–777PubMedCrossRefGoogle Scholar
  16. 16.
    Katz A, Soodeen RA, Bogdanovic B, De Coster C, Chateau D (2006) Can the quality of care in family practice be measured using administrative data? Health Serv Res 41:2238–2254PubMedCrossRefGoogle Scholar
  17. 17.
    Saag KG, Olivieri JJ, Patino F, Mikuls TR, Allison JJ, MacLean CH (2004) Measuring quality in arthritis care: the Arthritis Foundation’s quality indicator set for analgesics. Arthritis Rheum 51:337–349PubMedCrossRefGoogle Scholar
  18. 18.
    Winslade N, Taylor L, Shi S, Schuwirth L, Van der Vleuten C, Tamblyn R (2011) Monitoring community pharmacist’s quality of care: a feasibility study of using pharmacy claims data to assess performance. BMC Health Serv Res 11:12PubMedCrossRefGoogle Scholar
  19. 19.
    Zerzan J, Benton K, Linnebur S, O’Bryant C, Kutner J (2010) Variation in pain medication use in end-of-life care. J Palliat Med 13:501–504PubMedCrossRefGoogle Scholar
  20. 20.
    Maddison AR, Fisher J, Johnston G (2011) Preventive medication use among persons with limited life expectancy. Prog Palliat Care 19:15–21PubMedCrossRefGoogle Scholar
  21. 21.
    Fede A, Miranda M, Antonangelo D, Trevizan L, Schaffhausser H, Hamermesz B, Zimmermann C, Del Giglio A, Riechelmann RP (2011) Use of unnecessary medications by patients with advanced cancer: cross-sectional survey. Support Care Cancer 19:1313–1318PubMedCrossRefGoogle Scholar
  22. 22.
    Sullivan AM, Lakoma MD, Matsuyama RK, Rosenblatt L, Arnold RM, Block SD (2007) Diagnosing and discussing imminent death in the hospital: a secondary analysis of physician interviews. J Palliat Med 10:882–893PubMedCrossRefGoogle Scholar
  23. 23.
    Costantini MDLS, Beccaro M (2011) Methodological issues in a before-after study design to evaluate the Liverpool Care Pathway for the Dying Patient in hospital. Palliat Med Dec 25(8):766–773CrossRefGoogle Scholar
  24. 24.
    Costantini M, Ottonelli S, Canavacci L, Pellegrini F, Beccaro M, Group LCPRICTS (2011) The effectiveness of the Liverpool care pathway in improving end of life care for dying cancer patients in hospital. A cluster randomised trial. BMC Health Serv Res 11:13PubMedGoogle Scholar
  25. 25.
    Shuman AG, Yang Y, Taylor JM, Prince ME (2011) End-of-life care among head and neck cancer patients. Otolaryngol Head Neck Surg 144:733–739PubMedCrossRefGoogle Scholar
  26. 26.
    Gomes B, McCrone P, Hall S, Koffman J, Higginson IJ (2010) Variations in the quality and costs of end-of-life care, preferences and palliative outcomes for cancer patients by place of death: the QUALYCARE study. BMC Cancer 10:400PubMedCrossRefGoogle Scholar
  27. 27.
    Beers MH (1997) Explicit criteria for determining potentially inappropriate medication use by the elderly. An update Arch Intern Med 157:1531–1536CrossRefGoogle Scholar
  28. 28.
    Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH (2003) Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 163:2716–2724PubMedCrossRefGoogle Scholar
  29. 29.
    Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC (2011) Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 29:1587–1591PubMedCrossRefGoogle Scholar
  30. 30.
    Nappa U, Lindqvist O, Rasmussen BH, Axelsson B (2011) Palliative chemotherapy during the last month of life. Ann Oncol: Off J Eur Soc Med Oncol/ESMO 22:2375–2380CrossRefGoogle Scholar
  31. 31.
    Silveira MJ, Kazanis AS, Shevrin MP (2008) Statins in the last six months of life: a recognizable, life-limiting condition does not decrease their use. J Palliat Med 11:685–693PubMedCrossRefGoogle Scholar
  32. 32.
    Riechelmann RP, Krzyzanowska MK, Zimmermann C (2009) Futile medication use in terminally ill cancer patients. Support Care Cancer 17:745–748PubMedCrossRefGoogle Scholar
  33. 33.
    Appari A, Carian EK, Johnson ME, Anthony DL (2011) Medication administration quality and health information technology: a national study of US hospitals. J Am Med Inform AssocGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  • N. J. H. Raijmakers
    • 1
    • 2
  • L. van Zuylen
    • 2
  • C. J. Furst
    • 3
  • M. Beccaro
    • 4
  • L. Maiorana
    • 4
  • P. Pilastri
    • 5
  • C. Rossi
    • 6
  • G. Flego
    • 7
  • A. van der Heide
    • 1
  • M. Costantini
    • 4
  1. 1.Department of Public HealthErasmus MC University Medical CenterRotterdamthe Netherlands
  2. 2.Department of Medical OncologyErasmus MC University Medical CenterRotterdamthe Netherlands
  3. 3.Palliative Care UnitStockholms Sjukhem and Karolinska InsitutetStockholmSweden
  4. 4.Regional Palliative Care NetworkIRCCS AOU San Martino-ISTGenoaItaly
  5. 5.Hospice M. Chighine, Regional Palliative Care NetworkIRCCS AOU San Martino-ISTGenoaItaly
  6. 6.Department of PneumonologyVilla Scassi HospitalGenoaItaly
  7. 7.Department of Internal MedicineVilla Scassi HospitalGenoaItaly

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