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2023 HSR&D/QUERI National Conference Abstract

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4077 — Provider and Family Caregiver Perspectives on De-intensifying Chronic Disease Medications in Veterans Affairs Nursing Home Residents Near End-of-Life

Lead/Presenter: Loren Schleiden,  COIN - Pittsburgh/Philadelphia
All Authors: Schleiden LJ (Center for Health Equity Research and Promotion, VA Pittsburgh), Klima G (Center for Health Equity Research and Promotion, VA Pittsburgh) Rodriguez KL (Center for Health Equity Research and Promotion, VA Pittsburgh) Ersek M (Center for Health Equity Research and Promotion, VA Philadelphia) Robinson J (Center for Health Equity Research and Promotion, VA Pittsburgh) Hickson RP (Geriatric Research, Education, and Clinical Center, VA Pittsburgh) Thorpe CT (Center for Health Equity Research and Promotion, VA Pittsburgh)

Objectives:
Nursing home (NH) residents with limited life expectancy or advanced dementia (LLE/AD) who are intensely treated for lipid, blood pressure (BP), or diabetes control may benefit from de-intensification of medications for these conditions, given lower potential to live long enough to benefit and higher risk of adverse effects. Little is known about the deprescribing process in the NH setting or the role of family caregivers. We sought to identify VA NH provider and family caregiver perspectives on deprescribing decisions for chronic disease medications near end-of-life.

Methods:
We purposively recruited healthcare providers and family caregivers from 15 VA Community Living Centers (CLCs) previously identified as having consistently higher vs. lower rates of deprescribing chronic disease medications in Veterans admitted with LLE/AD. Physicians, nurse practitioners (NP), pharmacists, and registered nurses working in selected CLCs were invited to participate via email and snowball techniques. To recruit caregivers, we partnered with the VA Bereaved Family Survey to share study information with the next-of-kin of Veterans with coronary artery disease, stroke/transient ischemic attack, diabetes, and/or hypertension who recently died in selected CLCs. Participants completed semi-structured telephone interviews lasting 30-45 minutes. Provider interviews focused on experiences with deprescribing statin, BP, and diabetes medications in CLC residents with LLE/AD, while caregiver interviews focused on experiences with prescribing decisions related to the Veteran’s chronic disease medications in the CLC in the last weeks of life. Two coders conducted thematic content analysis on interview transcripts to identify key themes regarding influences on deprescribing in this context.

Results:
Providers (n = 13) included six nurse practitioners, three physicians, two pharmacists, and two registered nurses; eight were white/non-Hispanic; 10 were women. Caregivers (n = 13) were mostly female (n = 12) and spouses (n = 7) of the CLC resident. Provider-perceived barriers to de-intensifying chronic disease medications in CLC residents near end-of-life included: 1) clinical factors suggesting continued benefits of current treatment (e.g., recent cardiovascular event); 2) conflicting care with other providers pursuing intense treatment; and 3) resistance to deprescribing by family caregivers that required time to work through. Provider-perceived facilitators of de-intensifying included: 1) obvious clinical signs of adverse drug reactions or being very near end-of-life; 2) personal philosophy of care to reduce drug burden near end-of-life; and 3) family caregiver involvement and acceptance of changing goals near end-of-life. Key caregiver themes consisted of: 1) high trust in providers about deprescribing decisions; 2) a general belief that chronic disease medications are needed and hesitancy to change them without a compelling reason; and 3) importance of clinical factors or Veteran behavior as justifying changes in medications.

Implications:
Resident clinical factors, agreement among multiple providers, strong provider commitment to reducing unnecessary polypharmacy, and caregiver buy-in are key factors in de-intensifying chronic disease medications near end-of-life.

Impacts:
Findings align with previously identified quantitative predictors of de-intensifying chronic disease medications in CLC residents near end-of-life, but add new insights about importance of fostering collaboration among providers and encouraging communication and education for family caregivers of patients with LLE/AD.