Appropriate medication use for people with palliative conditions in general practice

Blog by project lead, assistant professor, GP (UMC Utrecht) and senior research fellow (University of Melbourne) Matthew Grant
During the last phase of life, some medications are no longer useful. Continuing the use of these medications no longer outweighs possible side effects and is not in line with the central goal of care in the palliative phase: optimizing the quality of life.


On my first day in internal medicine, my first patient was Iris, a 90 year old lady with mild dementia and heart failure. The family all sat by her bedside, holding her hand and telling stories about their mum. She lay unresponsive in bed, apparently in the terminal phase. Her treatment focused on comfort in the palliative phase. In the coming days she became more and more alert. On further examination she was clinically stable, but was using 11 different medications including digoxin. A blood test showed a digoxin level 5 times the normal level, which is frequently fatal. A week later she was back to her normal self, and discharged home. All but 3 of her medications were stopped.

A year later I was working at the hospice, and Iris was admitted in the terminal phase after an apparent stroke. She died later that day, again surrounded by her family. The daughter described a great year with her mum, that none of them had expected. 

Excessive use of medication

Patients like Iris frequently use large numbers of medications. For patients with palliative conditions this is even more common, with an average of 10 different medications. As patient’s clinical circumstances change, these medications may become inappropriate, such as cholesterol and blood pressure medications. About 80% of patients with palliative conditions use potentially inappropriate medications in the last year of life, and 30% of patients continue to use these medications up until their death. In vulnerable patients, these medications have a higher risk of side effects and interactions, which may result in costs for the patient, unwanted hospitalisations, and a poorer quality of life. 


With our PASVORM-project we are going to integrate routine medications reviews into General Practitioner (GP) care for patients with palliative conditions, to enable appropriate medication use for patients, and reduce unwanted side-effects and hospitalisations. We are implementing an intervention in 6 GP practices in the Utrecht region, where medications reviews and monitoring will be done as part of routine care through practice nurses, pharmacists and GPs. We are supporting health care professionals with these medications reviews through education, communication strategies for talking to patients about medication use, and through the use of the STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy) guidelines. 

Optimal medication management for patients

The project is also focusing on informing and educating patients about appropriate medication use, and encourage them to engage in these discussions with their primary care health care professionals. A patient and carer representative is a key member of the project group and informs the development of the project at all points.

Through these medication reviews we hope that patients receive optimal medication management that is appropriate to their needs and wishes, and reducing the number of medication and unwanted side effects. The main outcomes will be the reductions in inappropriate medication use, hospital admissions, side-effects, and the acceptability of integration into routine care.


Our project began in May 2024. We are currently finalising the protocol and the practical method implantation of routine medication reviews into primary care. The first medication reviews begin in September 2024 in a single GP practice. Later we expand this to a further 5 GP practice.

In addition to understanding the effects of routine medication reviews for patient with palliative conditions, we seek to understand the factors that facilitate uptake. Using these results, we are going to explore how routine medication reviews can be broadly implemented into practice through the primary care and inform clinical guidance documentation.

Healthcare innovations and quality

In recent years, much has been developed in knowledge, innovative forms of financing and interventions to achieve better palliative care in practice. Our program Palliantie II contributes to the (better) use of developed knowledge in practice, both by healthcare providers and by patients and their loved ones. Improvements in practice must contribute to (realizing) better quality of care in accordance with the quality framework. ZonMw contributes to this by financing implementation and effect studies and knowledge and further development of innovations.