Antipsychotics for delirium in palliative care

New RCT suggests non-drug alternatives are needed | The Mental Elf

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A recent meta-analysis of antipsychotics for delirium (Kishi et al, 2016) included trials comparing antipsychotics to usual care and placebo amongst a variety of settings, not specifically palliative care. There was similar size in effectiveness of antipsychotics compared to both placebo and usual care for response rates at study endpoint (with a very good Number Needed to Treat of 2) but only 1 placebo controlled study. There was no difference between antipsychotics and placebo on severity of delirium in the 1 study that measured this; there was a large effect size advantage for antipsychotics compared to usual care, but the placebo comparison is more relevant. There was a non-significant advantage for haloperidol compared to newer antipsychotics for rate of response, but a significant advantage for newer antipsychotics to reduce time to response. Antipsychotics were associated with a higher rate of side-effects.

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Improving the quality of care in the last days of life: A practical guide to getting the medications right

London Clinical Networks. Published online: 14 July 2016

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This document identifies best practice in the way medications should be managed in the last days of life. It sets out high level, evidence-based recommendations to help guide those responsible for care to review their processes and consider ways to make change where necessary.

This document aligns with Statement 11 in the NICE Quality Standard 13, End of life care for adults by addressing what needs to be done with people’s medications so that the care they are offered remains coordinated and delivered in the best way possible.

NHS England’s publication Actions for end of life care: 2014-162 sets out its commitment for statutory and voluntary partners in health and social care to work together to develop a vision for end of life care in future. This work is being carried out by the Ambitions for End of Life Care Partnership . The Partnership aims to transform experiences of end of life care by focusing on what would improve person-centred care, encouraging local communities to engage with the need for high quality care at the end of life, highlighting what would enable better coordination of care in the last days of life, and supporting networks of facilitators and champions.

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A phenomenological qualitative study exploring medicines use in palliative care patients, carers and healthcare professionals.

Todd, A. et al. BMC Palliative Care. 2016 15:13

Background: There is a growing body of evidence suggesting patients with life-limiting illness use medicines inappropriately and unnecessarily. In this context, the perspective of patients, their carers and the healthcare professionals responsible for prescribing and monitoring their medication is important for developing deprescribing strategies. The aim of this study was to explore the lived experience of patients, carers and healthcare professionals in the context of medication use in life-limiting illness.

Methods: In-depth interviews, using a phenomenological approach: methods of transcendental phenomenology were used for the patient and carer interviews, while hermeneutic phenomenology was used for the healthcare professional interviews.

Results: The study highlighted that medication formed a significant part of a patient’s day-to-day routine; this was also apparent for their carers who took on an active role-as a gatekeeper of care-in managing medication. Patients described the experience of a point in which, in their disease journey, they placed less importance on taking certain medications; healthcare professionals also recognize this and refer it as a ‘transition’. This point appeared to occur when the patient became accepting of their illness and associated life expectancy. There was also willingness by patients, carers and healthcare professionals to review and alter the medication used by patients in the context of life-limiting illness.

Conclusions: There is a need to develop deprescribing strategies for patients with life-limiting illness. Such strategies should seek to establish patient expectations, consider the timing of the discussion about ceasing treatment and encourage the involvement of other stakeholders in the decision-making progress.

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