Matthew D. Clark, Pharm.D.
The leading cause of death in the United States is cardiovascular disease. With the rise in the number of tobacco users along with our society’s push for fast food, this statistic should come as no surprise. Cardiovascular diseases can range from heart attack and stroke to congestive heart failure. What commonly accompanies these diseases is hypertension, or high blood pressure. Your body produces a substance called renin which leads to vasoconstriction that ultimately leads to high blood pressure. High blood pressure can also lead to kidney damage. In addition to hypertension, people with cardiovascular issues tend to have high levels of cholesterol. Astonishingly, our bodies contain both good and bad cholesterol. Low-density lipoproteins (bad cholesterol) hang out in our vascular system while our high-density lipoproteins (good cholesterol) work to transport our bad cholesterol to the liver to be metabolized. Build-up of bad cholesterol leads to plaque formation which ultimately leads to stroke. Fatty foods such as hamburgers and pizza can increase levels in bad cholesterol.
Elevated blood pressure and cholesterol ultimately lead to adverse cardiovascular events that can often lead to death. In order to avoid these events, patients are prescribed agents that lower blood pressure and cholesterol. It is common for patients to be on these classes of medications for numerous years. What about patients in hospice who are approaching the end of life? Is it appropriate for these patients to continue strict control on their blood pressure and cholesterol? Indeed, cardiovascular risks are very serious; however, these events are usually the long term effects of uncontrolled blood pressure and cholesterol. Therefore, the need for these medications at the end of life becomes moot. These medications can actually adversely affect the dying patient. For example, tightly controlling a patient’s blood pressure with medications can sharply drop their blood pressure which leads to falls and injury. Additionally, a certain group of cholesterol medications known as “statins” can lead to muscle breakdown and wasting in patients who are bed bound. As a result, these medications are commonly discontinued in hospice patients.
A goal for healthcare providers in hospice is to provide optimal comfort to the patient during the final moments of their life. One way to accomplish this is to minimize the amount of unnecessary medications the patient is taking. As frightening as stopping blood pressure and cholesterol medications may be, patients and families must realize that healthcare professionals, such as pharmacists, weigh the risks versus benefits of discontinuing medications. In this case, the risks of adverse events caused by continuing these medications outweigh the benefits of cardiovascular protection these medications provide for hospice patients. Cardiovascular medications are just one of many medication classes that can benefit hospice patients by being discontinued.