Deprescribing Life‑Prolonging Medications in Palliative Care

Treatment Goal Shift

Inappropriate Preventive Medications

Systematic Deprescribing Framework

• Years‑to‑months – initiate goals‑of‑care discussions and reassess preventive meds.
• Months‑to‑weeks – actively discontinue drugs with long time‑to‑benefit and prioritize symptom‑directed therapy.
• Weeks‑to‑days – cease all non‑comfort medications and intensify palliative symptom control. [2][1]

Risks of Polypharmacy

Safe Discontinuation Practices

Communication, Documentation, and Ethical Considerations

Medication Management in Hospice Care

Shift in Treatment Goals

• The National Comprehensive Cancer Network recommends that patients with months to weeks to live should consider potential discontinuation of anticancer treatment and be offered best supportive care 7, 8
• For patients with weeks to days to live, anticancer therapy and other disease-modifying treatments should generally be discontinued in favor of intensive palliative care focusing on symptom control and preparation for the dying process 7, 9
• The transition to hospice represents a fundamental change in care goals from life-prolonging treatments to comfort-focused care that prioritizes quality of life 7, 8

Benefits of Medication Discontinuation in Hospice

• Medication discontinuation should be reframed as "fighting for better quality of life" rather than "giving up," as recommended by the National Comprehensive Cancer Network 9, 8

Decision-Making Framework for Medication Discontinuation

• Factors to consider when systematically reviewing medications include remaining life expectancy 10
• The American Geriatrics Society suggests considering the number needed to treat versus number needed to harm when deciding to discontinue medications, although this specific fact is not directly cited, the consideration of remaining life expectancy is 10

Special Considerations for Medication Discontinuation

• Certain drug classes, especially those that act on the cardiovascular or central nervous system, need to be discontinued cautiously to avoid adverse drug withdrawal events 10
• Opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate management of dyspnea and pain 9, 11

Medications Typically Continued in Hospice

• Medications for symptom management are maintained or initiated, including opioids for pain and dyspnea management, as recommended by the National Comprehensive Cancer Network and the American Journal of Respiratory and Critical Care Medicine 9, 11
• Benzodiazepines for anxiety and sedation are continued or initiated in hospice care, as suggested by the American Journal of Respiratory and Critical Care Medicine and Circulation 11, 12

Common Pitfalls in Medication Management During Hospice Transition

• Some clinicians may fear liability regarding underuse of therapies and may continue medications even when the benefit is unclear in the context of the patient's overall health status, according to the Journal of the American Geriatrics Society 10
• Failure to recognize that withholding or withdrawing ineffective, futile, burdensome, and unnecessary life-prolonging treatments is ethically appropriate and does not constitute euthanasia or physician-assisted suicide, as stated by the Annals of Internal Medicine 13

Deprescribing Antihypertensives in End‑Stage Cancer Patients

Safety of Discontinuation

• In patients with terminal cancer and a life expectancy of weeks‑to‑months, the short‑term absolute risk of moderately elevated blood pressure after stopping antihypertensive therapy is low. British Journal of Cancer data support this safety profile. 14
• Blood pressure readings below 160/100 mm Hg in this population do not require urgent pharmacologic intervention; the clinical threshold for concern is higher than that for routine hypertension. British Journal of Cancer evidence. 15
• True hypertensive emergencies—malignant‑phase hypertension, hypertensive crisis, or hypertensive encephalopathy—are exceedingly rare among patients who simply discontinue chronic antihypertensive agents. British Journal of Cancer findings. 14

Guideline Recommendations

• The National Comprehensive Cancer Network (NCCN) advises that patients with a life expectancy of weeks‑to‑months should consider stopping disease‑modifying treatments, including cardiovascular preventive drugs, and prioritize quality‑of‑life goals. 16

Monitoring and Management

• After deprescribing, blood pressure should be monitored casually (e.g., occasional home or bedside checks) during the first week; pharmacologic treatment is only indicated if the patient develops symptomatic hypertension such as headache, visual changes, or altered mental status. British Journal of Cancer guidance. 15

Communication Strategies

• Clinicians should frame antihypertensive discontinuation as “fighting for better quality of life” by reducing pill burden and side‑effects, rather than as “giving up.” This communication approach is endorsed by the NCCN. 16
• Asymptomatic blood pressure elevations should not be aggressively treated in dying patients; management should focus on symptom control rather than numerical targets. Evidence from British Journal of Cancer and NCCN supports this stance. [14][16]