If you’ve ever helped as a caregiver to someone in the
twilight years of their life, or perhaps you yourself are at this stage, you
may have noticed when it was medication time that there were a lot of
pills. It is true there are exceptions
to this rule, those individuals who only take one or two medications a
day. However this is the exception, and
there doesn’t seem to be much middle ground. Either you are on pages worth of
medication, or hardly any as you begin to enter the last stages of life.
The first question is, how does this happen? A large culprit to this phenomenon stems from
the expectations for the doctor/patient encounter. When a patient comes to see a provider with a
specific complaint, they expect a remedy.
The unspoken words from every patient are “fix me”. While most complaints aren’t easy to
alleviate quickly, culture demands instant relief. Thus, handing out a new medication for a
complaint certainly feels like the problem has been addressed. This is not much
different to what happens when my 3 year old skins his knee. He has been enculturated to believe that with
any scrape a Band-Aid is the ultimate solution.
As a parent, I can tell that most of his injuries medically don’t need
Band-Aids, and yet when I relent I’m amazed at the immediate soothing effect it
has because something has been done to “fix” him. Medications at times are like Band-Aids, they
may not be essentially needed, but we expect something from them, and so in
turn, they pacify us.
The next issue with medications is the tendency that once
started they are never stopped. Someone
comes into the hospital for knee surgery and complains of indigestion due to
anxiety about the surgery, so an antacid is prescribed. The person is discharged with the new
medication, and years later are still taking it, despite not medically needing
it. When I put a Band-Aid on my 3 year old,
it takes some convincing after a day that I can remove it, because he is now
healed. How funny it would be if we left
Band-Aids on indefinitely, never evaluating if the injury healed. Yet this is often the case for pills, started
by other specialists, or for specific reasons in the past, we trust their
benefit, like the Band-Aid, without pondering if still needed.
When it comes to end of life, the harm of over prescribing
and not eliminating medications is something called ‘pill burden’. Patients fatigued from their disease and
having more difficulty swallowing become burdened by the handful of medications
we expect them to take. Many pills can
be eliminated because of the above scenarios, but even more can be stopped when
we evaluate why someone is taking the pill in the first place.
Many medications prescribed are preventative, meant to stave
off unwanted future risks. Some of these
drug classes are blood thinners, cholesterol lowering agents, blood pressure
medications, dementia medications, and all vitamins. These agents are meant to prevent things
years in the future, so it makes no sense continuing them on hospice when time
is limited.
Pill burden doesn’t just occur at the end of life. It’s okay
to be an advocate and sit down with your physician to discuss the necessity of
medications prescribed. The key is to
ensure the pills you take are working for you, because it can be work to take
them in the first place.
