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Objective: The objective of this analysis was to examine the use of 11 non-essential medications in actively dying patients., Methods: This was a planned secondary analysis of data from the Best Practices for End-of-Life Care for Our Nation's Veterans trial, a multicentre implementation trial of an intervention to improve processes of end-of-life care in inpatient settings. Supported with an electronic comfort care decision support tool, intervention included training hospital staff to identify actively dying patients, communicate the prognosis to patients/families and implement best practices of traditionally home-based hospice care. Data on medication use before and after intervention were derived from electronic medical records of 5476 deceased veterans., Results: Five non-essential medications, clopidogrel, donepezil, glyburide, metformin and propoxyphene, were ordered in less than 5% of cases. More common were orders for simvastatin (15.8%/15.1%), calcium tablets (8.4%/7.9%), multivitamins (11.6%/10.8%), ferrous sulfate (9.1%/7.6%), diphenhydramine (7.2%/5.1%) and subcutaneous heparin (29.9%/27.5%). Significant decreases were found for donepezil (2.5%/1.3%; p=0.001), propoxyphene (0.8%/0.1%; p=0.001), metformin (0.8%/0.3%; p=0.007) and multivitamins (11.6%/10.8%; p=0.01). Orders for one or more non-essential medications were less likely to occur in association with palliative care consultation (adjusted OR (AOR)=0.64, p<0.001), do-not-resuscitate orders (AOR=0.66, p=0.001) and orders for death rattle medication (AOR=0.35, p<0.001). Patients who died in an intensive care unit were more likely to receive a non-essential medication (AOR=1.60, p=0.009), as were older patients (AOR=1.12 per 10 years, p=0.002)., Conclusions: Non-essential medications continue to be administered to actively dying patients. Discontinuation of these medications may be facilitated by interventions that enhance recognition and consideration of patients' actively dying status., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

In spite of ethical analyses assimilating the palliative deactivation of pacemakers to commonly accepted withdrawings of life-sustaining therapy, many clinicians remain ethically uncomfortable with pacemaker deactivation at the end of life. Various reasons have been posited for this discomfort. Some cardiologists have suggested that reluctance to deactivate pacemakers may stem from a sense that the pacemaker has become part of the patient's "self." The authors suggest that Daniel Sulmasy is correct to contend that any such identification of the pacemaker is misguided. The authors argue that clinicians uncomfortable with pacemaker deactivation are nevertheless correct to see it as incompatible with the traditional medical ethics of withdrawal of support. Traditional medical ethics is presently taken by many to sanction pacemaker deactivation when such deactivation honors the patient's right to refuse treatment. The authors suggest that the right to refuse treatment applies to treatments involving ongoing physician agency. This right cannot underwrite patient demands that physicians reverse the effects of treatments previously administered, in which ongoing physician agency is no longer implicated. The permanently indwelling pacemaker is best seen as such a treatment. As such, its deactivation in the pacemaker-dependent patient is best seen not as withdrawal of support but as active ending of life. That being the case, clinicians adhering to the usual ethical analysis of withdrawal of support are correct to be uncomfortable with pacemaker deactivation at the end of life.

To identify aspects of end-of-life care in the U.S. Department of Veterans Affairs (VA) health care system that are not assessed by existing survey instruments and to identify issues that may be unique to veterans, telephone interviews using open-ended questions were conducted with family members of veterans who had received care from a VA facility in the last month of life. Responses were compared to validated end-of-life care assessment instruments in common use. The study took place in four VA medical centers and one family member per patient was invited to participate, selected from medical records using predefined eligibility criteria. These family members were asked to describe positive and negative aspects of the care the veteran received in the last month of life. Interview questions elicited perceptions of care both at VA sites and at non-VA sites. Family reports were coded and compared with items in five existing prospective and retrospective instruments that assess the quality of care that patients receive near the end of life. Interviews were completed with 66 family members and revealed 384 codes describing both positive and negative aspects of care during the last month of life. Almost half of these codes were not represented in any of the five reference instruments (n=174; 45%). These codes, some of which are unique to the veteran population, were grouped into eight categories: information about VA benefits (n=36; 55%), inpatient care (n=36; 55%), access to care (n=33; 50%), transitions in care (n=32; 48%), care that the veteran received at the time of death (n=31; 47%), home care (n=26; 40%), health care facilities (n=12; 18%), and mistakes and complications (n=18; 27%). Although most of the reference instruments assessed some aspect of these categories, they did not fully capture the experiences described by our respondents. These data suggest that many aspects of veterans' end-of-life care that are important to their families are not assessed by existing survey instruments. VA efforts to evaluate end-of-life care for veterans should not only measure common aspects of care (e.g., pain management), but also examine performance in areas that are more specific to the veteran population.