Withdrawing Some Routine Medications:
When is it appropriate?
When is it appropriate to withdraw regular medications? This is a common question which will confront all who care for the dying. A common scenario follows:
[names withheld for confidentiality purposes] "My parent was admitted to the hospice program over the last several days. She has been described by the hospice staff as at the "middle of the book" stage of dying. Her condition is terminal, but she's not at the very end active phase of dying." "Part of her regular medication has been a blood thinner which was regulated by frequent blood tests and adjustment of the dosage when her blood would become too thin." "At this point, the hospice has decided to stop the blood thinning medicine because they say her body is not metabolizing it. This is certain to cause her blood to thicken and result in stroke. The doctor has confirmed this but says withdrawing the medication at this time is "perfectly acceptable" in a hospice situation."
"I am not comfortable at all with the decision because I think it will effectively result in causing her death by stroke and would amount to euthanasia. Do I have a right to insist on continuing with the regular blood tests and adjustment of the Coumadin as necessary? Or do you agree that withdrawing the medication is acceptable in a hospice situation?"
Well, hospice is supposed to be about providing comfort for the dying, neither hastening death nor prolonging life by attempting to cure the terminal illness. Patient's retain the right to continue their regular medications even in a hospice situation. If a patient has high blood pressure, for example, as well as cancer, removing a blood pressure medication before they enter the very last stage (called the active phase of dying) would amount to actively choosing to hasten death and make the patient die before they would naturally if the terminal illness were to be allowed to run its full course.
Removing a needed "blood thinner" (anti-coagulent) for a heart patient, would likely cause stroke, pulmonary embolism or even a heart attack, and would likely cause death earlier than when the terminal heart condition would naturally end the patient's life. Also, in the scenario presented above, the statement that her body is "not metabolizing the blood thinning medication" could be questioned. Who says so? And why would her body not be metabolizing the Coumadin when there is no mention of other organ disease process. Some statements made by hospice staff may not be accurate and may only be made to rationalize their decision to hasten the patient's death ... to explain away why they are yanking away the medications needed by the patient.
It is normal and acceptable to remove regular medications during the very end stage of dying, what is called "active phase of dying," since the patient's body will not be benefited by them and all the systems and organs are shutting down and collapsing in the process of death. (See our page on Signs and Symptoms of Dying for more information on what the various phases of dying look like) At this stage, the patient often has difficulty swallowing, may not absorb the medications due to dehydration as well as liver and other organ failure, and giving the medications may be more troublesome than any benefit they could offer. At the very end active phase of dying, only comfort medications are given so that the patient is allowed to die without suffering. At this point, there is absolutely no way of preventing death anyway, and any of the ordinary routine medications the patient used to take have no medical justification or value.
In a patient that is not at the end, removing the medications is a form of hastening death or euthanasia. It is the role of the palliative care professionals to respect the wishes of the patient and not push the patient to stop medications if they want to continue them. Some hospices will routinely take actions that shorten a patient's life when they know that the end stage phase of dying will be service intensive ... requiring many hours of service to handle. Other hospices would never think to remove such medications until the very end. Simply taking in patients while care is routine (and least expensive to provide) while avoiding intensive active phase of dying crises allows the hospice to maximize revenue while minimizing services delivered. In the scenario presented above, the patient's son was there to advocate for the parent's needs and see that her wishes were respected. Hospice is about allowing a natural death while promoting dignity and relieving suffering.