Optimizing care at the end of life: Decision-making on medication with an emphasis on antithrombotics

Patients in the last phase of life often use many medications until shortly before death. In the last phase of life, the main goal of care is usually no longer prolonging life or curing illness, but relieving suffering. On the one hand, medication can improve the quality of life and dying, but on the other hand, too much or inappropriate medication can harm patients with life-threatening illness. Bregje Huisman’s thesis aims to provide insight into medication use in the last phase of life and decision-making concerning medication use, and formulate recommendations to promote appropriate decision-making. This thesis includes data from a questionnaire study, an interview study, a Delphi study, a mixed method study and a retrospective chart review study from the MEDIcation management in the LAST phase of life (MEDILAST) project. The first part of the thesis presents the insights of health care providers regarding medication use in the last phase of life and the role of the nurse in this process. It shows that physicians agree that patients take too many medications at the end of life, but that they frequently prescribe patients medication for chronic diseases of which the benefit at the end of life is debatable. Results from the interview study indicate that nurses can have a pivotal role in communication and collaboration regarding medication, with patients, informal caregivers and physicians, by informing, supporting, representing and involving the other parties. In the Delphi study, experts reached a high level of consensus on recommendations to improve medication management in end-of-life care, concerning awareness, education and timely communication about medication. In second part, the use of antithrombotics and decision-making regarding antithrombotics are described. Antithrombotics are usually prescribed to improve the prognosis and quality of life of patients by preventing or treating thromboembolic events. At the end of life, its use should be reconsidered because the balance of benefit and harm may change and both bleeding and thromboembolic complications can lead to acute and serious situations. Results in this part show that antithrombotics are often continued until shortly before death. Physicians agree that the primary goal of medical care in the last phase of life is to improve or maintain the patient's quality of life, but whether this requires stopping or continuing an anticoagulant is often a dilemma for physicians. In this thesis a first step towards guidance is proposed for antithrombotic management and for discussing the use of antithrombotics at the end of life with patients. In the third part recommendations for clinical practice and further research are described. There is a need for education in communication and identification of the last phase of life. To optimize medication use in the last phase of life, medication assessment should ideally be incorporated in advance care planning conversations. Thereby, anticipating future problems and death scenarios can contribute to appropriate patient care.