Cardiac Medications Continuation Versus Discontinuation at End-of-Life: A Retrospective Analysis of Clinical Outcomes

Abstract

Background

Information regarding cardiac medication management for patients with Heart Failure, Atrial Fibrillation, and Coronary Artery Disease at end of life (EOL) is limited. This study evaluated symptoms and medication utilization patterns at EOL.

Methods

Retrospective review of cardiac patients admitted to a palliative care unit (PCU) at a quaternary center in New York. Demographics, length of stay, LACE score, utilization of cardiac and symptom medications, and oral morphine equivalents (OME) were collected. Respiratory Distress Observations Scale (RDOS) and pain assessment in advanced dementia (PAINAD) evaluated symptoms.

Results

Among 176 patients (median age 82.0 years [IQR 75.0-89.0], 50% males, 69.9% white), 53.4% discontinued cardiac medications prior to or on PCU admission, 24.4% during PCU stay, 7.4% showed mixed patterns, and 14.8% continued medications. Multivariate analysis revealed significant interactions between heart failure status and discontinuation patterns (β = 0.224, p = 0.012). Patients discontinuing medications during PCU showed higher rates of severe pain (PAINAD ≥6: 37.2% vs 3.8% in continuation group, RR = 9.79, 95% CI: 2.47-38.82). Both early discontinuation and during-PCU discontinuation groups demonstrated significantly larger increases in opioid doses (median increases 28 mg and 36.6 mg respectively vs 14 mg and 11 mg in continuation groups, p < 0.001), a pattern most pronounced in heart failure patients, with the model explaining 46.3% of variance in final opioid requirements.

Conclusion

While most cardiac medications were discontinued before PCU, discontinuation was associated with higher opioid requirements and pain scores, particularly in heart failure patients. These findings challenge current practices and highlight the need for evidence-based protocols for cardiac medication management at EOL.