Every medication choice in hospice is crucial. Keeping therapies streamlined to those that offer multi-symptom benefits and truly align with the patient’s goals of care is key.

A prescribing cascade illustrates how a single medication can lead to a domino effect of new prescriptions. A classic example starts with amlodipine:

Amlodipine –> Increased Ankle Edema –> Furosemide Added –> Increased Urine Output & Bathroom Visits –> Fall & Injury –> Opioid Started –> Constipation –> Laxative Started –> GI Upset –> PPI Started….

This cascade shows how a common side effect, lower leg edema with amlodipine, can lead to a complex and dangerous cycle of polypharmacy. Hospice patients are already at high risk for falls, pain, and constipation. By adding more medications, we compound these risks.

When faced with a new symptom, ask yourself these questions:

• Is this symptom a side effect of a medication we recently added, stopped, or changed?
• If we add a new treatment, what other effects could it have and how do we monitor for those?
• Are we able to remove a medication while adding this new one?

For this particular scenario, understanding the patient’s blood pressure history, including a sitting to standing measurement since the patient appears to be ambulating. Asking the question why do we treat blood pressure to begin with and what are we targeting as a goal in hospice. Understanding the general lack of evidence on the use of amlodipine as a treatment. Checking the skin turgor to see how “hydrated” the patient is despite the edema. Hospice Clinical Pearl: Checking skin turgor in hospice patients on the clavicle area is one of the best spots. Understanding that lower leg edema in hospice is not uncommon due to decline in mobility, decreased intake leading to low albumin levels and malnutrition and ultimately third spacing etc. Even if the amlodipine isn’t the sole cause of the edema, deprescribing it when appropriate will often improve the symptoms or at least allow for a reduced dose of the furosemide, lessening the risk of continuing the cascade.

Building a deprescribing mindset into your routine is a fundamental part of hospice care. It helps eliminate unnecessary medications and reduces the cumulative effects of polypharmacy in a frail population, ultimately improving comfort and quality of life.