The majority of seriously ill Canadians die during or immediately following an admission to an acute hospital, where the focus is often on reversing acute conditions rather than providing comfort care for patients with a short prognosis. Among seriously ill Canadians who die in hospital, only a small fraction receive palliative care, and very few are satisfied with the attention paid to palliative issues such as symptom control. The focus on acute illness can persist even to those who are receiving palliative care. In our hospital, more than half of the medications given to dying patients treated with a palliative intent in the final week of life were not for comfort, while some acutely deteriorating patients are never offered comfort medications prior to death.
Polypharmacy is a common problem in Canada. Approximately two-thirds of Canadian seniors are taking more than 5 medications regularly, and 30% of those over age 85 are taking more than 10 medications. Elderly patients are even more likely to be taking multiple medications, and those who do are at elevated risk of medication errors, medication interactions, adverse drug reactions and noncompliance. Many of these medications are effective for treating or preventing illness, but some are not appropriate for the seriously ill. Up to 40% of elderly patients are prescribed medications that are potentially inappropriate for them according to guidelines, and up to 30% of hospital admissions for patients over age 75 are medication-related; most of these are preventable. Inappropriate medications are also burdensome to patients, and may be very time consuming for nurses to prepare. The financial costs of this behaviour can be staggering- one study estimated that the use of potentially inappropriate medications among community-dwelling seniors in the US alone cost $7.2 billion in 2001. In Canada, medications are often partially borne by patients themselves, meaning that polypharmacy can have an important economic impact on patients themselves.
Many hospitals already employ pharmacy-focused quality improvement projects such as medication reconciliation and antibiotic stewardship, which have led to significant improvements in patient safety and reductions in cost. We propose to conduct a pilot study of an innovative MEdication RAtionalization (MERA) team on the General Medical Inpatient ward. The MERA team would include members of multiple disciplines (medicine, pharmacy, nursing) that would meet regularly with admitting physicians to review the medications prescribed for any patient meeting specific age and illness criteria. The team would review the rationale for each medication, recommend discontinuing any non-comfort medication that has no clear short-term benefit to the patient (e.g. statins), and suggest adding orders for comfort medications (e.g. opioids, sedatives) as needed. The summary recommendations will be proposed to the patient or substitute decision-maker, and changes will be made only with their consent.
Drs. James Downar, Kirsten Wentlandt, Ebru Kaya, Isaac Bogoch