MDS Alert

The total number will likely decline but the mix should change.

Palliative care is about promoting comfort, not cure, so take a look to see if a dying resident's medications reflect that shift in goals.

When a resident is close to death, many times you'd expect to see a reduction in certain medications, such as insulin and diuretics, if the person isn't eating and drinking as much, says Steven Littlehale, RN, MSN, with LTCQ Inc. in Lexington, MA.

Or the physician might discontinue thyroid replacement therapy, anti-cholesterol medications or some osteoporosis medications, adds Carla Saxton, RPh, CGP, with the American Society of Consultant Pharmacists. There can be exceptions. For example, the nasally administered Miacalcin (calcitonin) has been found to decrease osteoporosis-related pain in some patients, says Saxton.

While the physician may be discontinuing maintenance and preventive care medications, you'd expect to see an increase in comfort medications, including ones for pain, depression, insomnia and constipation,  says Littlehale.

For patients with a painful end-stage condition, you'd expect to see a long-acting opioid and PRN medication for breakthrough pain, says Saxton. "You might also expect to see Ativan or a benzodiazepine for anxiety, especially anxiety related to dyspnea, where the person becomes anxious at not being able to catch his breath," says Saxton. "Despite its side effects, morphine is sometimes administered via a nebulizer to help ease breathing problems/dyspnea near the end of life."

Check Section O: As an indicator of quality end-of-life care, you'd predict the sum total of medications may decline (as coded in Section O1), although the prescribing clinician may add a few medications (coded in O2) and psychoactive medications (O4).

In a recent research project analyzing residents' MDSs at the end of life, LTCQ found this indicator 98.4 percent of the time in nursing facilities specializing in end-of-life care. But facilities without that specialization were meeting the indicator only 60 percent of the time, according to Littlehale.