Pharmacotherapy in older people receiving palliative care in hospice settings

: Prescribing, deprescribing and medicines optimisation

Abstract

Multimorbidity is common in older patients. Consequently, polypharmacy and potentially inappropriate prescribing (PIP) are prevalent and increase toward the end of life (EOL). One potential solution is deprescribing, a supervised discontinuation of inappropriate medicines. The overall aim of this thesis was to explore prescribing and deprescribing patterns in hospice care settings, to evaluate current deprescribing interventions, to determine deprescribing barriers and enablers from the perspectives of healthcare professionals (HCPs) and policymakers, and to evaluate the attitudes of HCPs, patients and carers in relation to deprescribing medicines for older people receiving palliative care. Qualitative and quantitative methodologies were used throughout the four studies described in this thesis. Key findings of the systematic review included the current lack of high-quality studies of deprescribing interventions in older people at the EOL. The limited number of included studies demonstrated a positive impact of deprescribing interventions on medication appropriateness but inconsistent effects on polypharmacy, and did not consider clinical and humanistic outcomes. Further key findings were the high prevalence of polypharmacy and PIP in older hospice patients in the last days of life, the largely reactive nature of current deprescribing practice, and the limited adoption of pre-emptive (proactive) deprescribing. Moreover, key barriers to deprescribing in hospice care were reported; for example, the lack of formal documentation of deprescribing outcomes, while access to information such as medication indication was identified as a key enabler. These barriers and enablers guided the prioritisation of key theoretical domains which were mapped to behavioural change techniques to be incorporated in future deprescribing interventions. Stakeholders involved in the deprescribing process (patients, carers, HCPs) showed willingness for medicines to be deprescribed. Overall, the findings highlight the complexity of prescribing in older people at the EOL and the need of further training and educational programs to optimise medicines use in this vulnerable population.

Thesis embargoed until 31 December 2024.

Date of Award	Dec 2021
Original language	English
Awarding Institution	Queen's University Belfast
Sponsors	Hashemite University
Supervisor	Carole Parsons (Supervisor) & Noleen McCorry (Supervisor)