Reply to Deprescription during last year of life in patients with pancreatic cancer: Optimization or nihilism? (2019)

We thank Dr. Capurso for his comments, which underscore the clinical and ethical challenges of prescribing for older adults with advanced cancer at the end of life. In our study, we demonstrated that preventive drugs often are continued until the final weeks before death and argued that deprescribing strategies are warranted to avoid unnecessary and potentially harmful treatments.1 Preventive medicines are not necessarily clinically inappropriate at the end of life because some may have important palliative indications to alleviate distressing symptoms or to avoid clinical complications that could impair quality of life. This is, for example, true in the case of antidiabetic agents prescribed to address the symptoms of chemotherapy-related or corticoid-induced hyperglycemia. Deprescribing efforts should thus consider different clinical, social, psychological, physical, and financial factors, all of which should place the patient in the center of the decision-making process. Optimization of drug therapy near the end of life should be done along 3 main lines: 1) keeping the treatments aligned with the patient's goals of care and priorities; 2) carefully balancing the expected benefits of the drugs with their potential for harm; and 3) gauging whether or not the time to benefit of the prescribed treatments still is compatible with the patient's estimated survival.2 It is important to remember that older individuals with advanced cancer often experience profound physiological changes (eg, weight loss, cachexia, and renal and/or hepatic impairment) that can alter pharmacokinetic and pharmacodynamic parameters. Ideally, prescribing for these patients should be accompanied by a comprehensive geriatric assessment to identify problems that otherwise would not be detected in routine clinical examination and to tailor treatments accordingly.3 Finally, optimization of drug therapy is about the simplification of drug regimens and the reduction of the overall pill burden. This is particularly important for patients whose functional independence is gradually compromised near the end of life and who thus rely extensively on family caregivers and other relatives for the administration of drugs, and who may find taking multiple medications increasingly burdensome. Arguing that there is room to develop deprescribing approaches for older patients with advanced cancer is neither nihilistic nor oversimplistic. We believe that our study provides important findings with which to inform the ongoing debate regarding the potential overuse of medical interventions at the end of life. Our study also supports the recent Choosing Wisely movement that has received international attention, whereby patients are encouraged to discuss the benefits and risks of their treatment with their treating physician. Deprescribing is a way to embrace the clinical complexity and prognostic uncertainty that comes with caring for vulnerable individuals, at a time when the question is no longer “is this drug effective?” but rather “will this drug help my patient in a meaningful way during the time that he/she has left?”. In other words, deprescribing near the end of life is not about denying older people access to treatments that could be beneficial. It is about avoiding harm and maintaining the best possible quality of life (eg, by choosing therapeutic alternatives that will have the least disruptive impact on the patient's everyday life). It also is about making sure that our impulse to provide a new treatment for each and every new health problem that arises during the course of the disease is concordant with what is important to the patient. No specific funding was disclosed. The authors made no disclosures.