Drug treatment at the end of life: An epidemiologic study in nursing homes

Figures & data

Table I. Injectable drugs recommended for palliative treatment for the dying in NHs in Norway [2,5], by proportion (%) of users on the day of death.

Drug name	ATC code	Common EOL use	Proportion (%) of patients
Morphine	N02AA01	Pain or dyspnoea	71.4
Glycopyrronium	A03AB02	Death rattle	46.9
Scopolamine	N05CM05	Death rattle	25.8
Morphine-scopolamine	N02AG01	Pain or dyspnoea and death rattle	12.2
Midazolam	N05CD08	Anxiety, agitation	55.0
Diazepam	N05BA01	Anxiety, agitation	1.0
Haloperidol	N05AD01	Nausea and terminal delirium	46.9

Table II. Patient characteristics (n = 524).

Median (range) age at death, years	86 (19–104)
Women, %	59.4
Median (range) length of stay, days	103 (0–1765)
Long-term care, %	68.1
Diagnoses:
Dementia, %	36.8
Congestive heart failure, %	29.6
Cancer, %	23.7
Chronic pulmonary disease, %	18.5
Infections, %	20.0
Hip fracture, %	9.7

Table III. Most common drugs on the date of death (% of patients).

ATC-code	Regular drugs Drug subgroup	Proportion (%) of patients	ATC-code	As-needed drugs Drug subgroup	Proportion (%) of patients
A06A	Laxatives	32.6	N02A	Opioid analgesics	82.6
N02A	Opioid analgesics	32.4	N05C	Hypnotics	70.4
N02B	Non-opioid analgesics and antipyretics	28.2	N05A	Antipsychotics	51.1
C03C	High-ceiling diuretics	26.7	N05B	Anxiolytics	30.9
B01A	Antithrombotic agents	24.0	N02B	Non-opioid analgesics and antipyretics	26.0
N06A	Antidepressants	19.1	A03A	Drugs for functional gastrointestinal disorders^1	24.6
C07A	Beta-blocking agents	17.6	C03C	High-ceiling diuretics	16.8
A02B	Drugs for peptic ulcer and gastro-oesophageal reflux disease	15.1	A03F	Metoclopramide	13.4
B03B	Vitamin B12 and folic acid	14.3	A06A	Laxatives	13.0
N05C	Hypnotics	13.5	C01D	Vasodilators used in cardiac diseases	11.1
N05A	Antipsychotics	11.5	R03A	Adrenergic inhalants	6.3
N05B	Anxiolytics	11.1	A10A	Insulins and analogues	5.2
C09A	ACE inhibitors, plain	8.6	B05B	i.v. solutions	4.8
H02A	Corticosteroids for systemic use, plain	8.4	R05C	Expectorants, excl. combinations with cough suppressants	4.6
R03A	Adrenergic inhalants	8.4	R03B	Other drugs for obstructive airways disease, inhalants	4.4

Note: ¹Glycopyrronium represented 84.8% of prescriptions in this category.

Table IV. Associations between palliative EOL drug therapy and patient characteristics.

	Proportion of patients (%) prescribed palliative drugs	Chi-square, p	AOR	95% CI
Nursing home:
A	52.7	< 0.01	1	Ref
B	78.7		3.53	1.91–6.00
C	80.4		4.20	2.26–7.08
Length of stay (quartiles):
< 2 weeks	81.2	0.01	1.86	0.97–3.25
2 weeks–3 months	65.1		1	Ref
3–16 months	71.8		1.70	0.97–3.17
> 16 months	78.6		2.10	1.13–3.95
Gender:
Women	75.8	0.31	1	Ref
Men	71.8		0.98	0.60–1.44
Age:
86+	77.4	0.06	1.03	1.005–1.05
< 86	70.0
No. of diagnoses:
> 6	76.6	0.21	Variable not included
< 6	71.7
Cancer:
No	71.5	0.01	1	Ref
Yes	83.1		2.12	1.30–4.13
Dementia:
No	72.2	0.16	1	Ref
Yes	77.7		1.43	0.88–2.25
Infections:
No	75.4	0.22	Variable not included
Yes	69.5
Chronic pulmonary disease:
No	75.2	0.30	Variable not included
Yes	70.1
Heart failure:
No	73.4	0.52	Variable not included
Yes	76.1
Hip fracture:
No	74.6	0.53	Variable not included
Yes	70.6

Notes: Logistic regression model: chi-squared (8, 524) = 58.41, p < 0.001, Cox & Snell R2 = 0.11, 74.4% correctly classified. The logistic regression was performed as a block analysis, each variable being adjusted by the effects of the others. Association strength is given as adjusted odds ratios (AORs), with 95% confidence intervals (CI). Only variables with a p < 0.20 in the chi-squared test were included in the regression analysis, with the exception of gender which was included on the basis of being a common confounder. In the regression model, age was analysed as a continuous variable, all other included variables as categorical. Ref = reference value.

Figure 1. Proportion of patients (%) for whom at least one palliative EOL drug was initiated, or at least one curative/preventive drug was discontinued during the last 14 days of life.

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