End of life prescription practices in hospice care are evolving, reflecting the growing focus on patient comfort, individualized symptom management, and minimizing unnecessary medication burdens. Let’s take a comprehensive look at the latest trends and challenges in this critical aspect of hospice care
What you’ll learn in this article:
- Polypharmacy is common at hospice admission but declines as unnecessary drugs are deprescribed.
- Prescriptions focus on relieving pain and distress, prioritizing comfort and quality of life.
- Use of comfort kit medications varies widely between hospice agencies.
- Deprescribing is vital for reducing medication burden and enhancing patient well-being.
- Regulatory changes in controlled substances and telemedicine may challenge hospice providers.
Rising Hospice Utilization and Medication Needs
Hospice utilization has reached record highs in the United States, with more than half of Medicare decedents (51.7% in 2023) receiving hospice care. This increased demand means more patients require tailored prescription medication regimens to manage varying complex symptoms in their final days.
From Polypharmacy to Deprescribing
A key trend in hospice care is the shift from polypharmacy—where patients are prescribed multiple medications for chronic conditions—to a more streamlined, symptom-focused approach, as patients near death. Studies show that while most hospice patients enter care with high rates of polypharmacy, the number of regularly prescribed medications decreases steadily until the time of death. This ‘deprescribing’ of unnecessary or potentially harmful drugs can improve patient comfort and reduce adverse effects, such as sedation, confusion, or falls.
More on Deprescribing: A Deliberate, Patient-Centered Process
‘Deprescribing’ is gaining recognition as a best practice in hospice care. Reducing unnecessary medications lessens side effects and drug interactions while improving patient-reported well-being. However, studies have also identified under-prescribing of essential symptom-control drugs, such as laxatives for patients on opioids, pointing to the need for balanced, individualized care.
Symptom Management: The Core of End-of-Life Prescribing
The primary goal of hospice pharmacotherapy is to relieve distressing symptoms. The most commonly prescribed medications at the end-of-life targ
- Pain (opioids and co-analgesics)
- Anxiety and agitation (benzodiazepines)
- Nausea and vomiting (antiemetics)
- Delirium (antipsychotics)
- Respiratory secretions (anticholinergics)
The most frequently addressed symptom is pain, with more than 80% of patients receiving analgesics in their final days. As death approaches, medications are often adjusted to routes better suited for patients who can no longer swallow, such as subcutaneous infusions, which allow for continuous symptom control.
Comfort Kits and Prescribing Variation
Many hospices provide “comfort kits” which are pre-packaged sets of medications for urgent symptom relief. However, there is significant variation among hospices in how and when these medications are prescribed, particularly for benzodiazepines and antipsychotics. Some agencies prescribe these drugs liberally, while others are more conservative, leading to a tenfold to fiftyfold difference in prescribing rates between agencies. This variation is influenced more by agency practices than by patient needs, highlighting the need for clearer guidelines and more consistent clinical decision-making.
Regulatory and Operational Challenges
Recent regulatory proposals, such as the DEA’s telemedicine prescribing rules, may impact how hospice physicians prescribe controlled substances (e.g., opioids, benzodiazepines) essential for end-of-life care. These changes could introduce new administrative burdens and affect timely access to symptom-relieving medications, especially as telemedicine becomes more common in hospice practice.
As hospice care continues to grow and evolve, ongoing research and updated guidelines will be crucial to ensure that medication practices remain patient-centered, evidence-based, and responsive to the unique needs of those at the end of life.