Deprescribing is patient-centered care

Deprescribing is patient-centered care

My name is Ashley Perreault, and I am now starting my third year of medical school at the Northern Ontario School of Medicine, based in Thunder Bay, Ontario, Canada. I have no conflicts of interest to disclose. I presented this discussion on April 21, 2022 while still a second-year medical student, to open a 2-hour workshop on Practical Deprescribing – a professional community approach, for doctors and pharmacists at the Society of Rural Physicians of Canada annual meeting.

You may wonder what a second-year medical student may know about deprescribing? Or why I care about this so early on in my education, when I should be spending my time learning the Krebs cycle for the 10th time?

What I can tell you is that prior to medical school, I worked as a registered nurse on a surgical step-down unit at the Ottawa Hospital and cared for patients post-operatively. It was here where I witnessed polypharmacy and the harmful implications it can have for patients. I could share how multiple medications made drug interactions more likely, or that aspirin for people at age 90 may not have been the best idea; but you probably already know this. I want to share with you some experiences I had with patients that really stuck with me. Probably you have had similar experiences of your own.

On a typical day where I worked, 1-3 patients were transferred to my unit each day after surgery. I was responsible for completing medication reviews with each patient. This meant I had to review every single medication that they took at home prior to surgery. Together we had to confirm the medication name, dose, frequency, route, and purpose. Often the patient could confirm the name, frequency, and route. But to my surprise, patients often did not know the dose of their medications or even their purpose.

How can this be? How can someone take a medication every day, refill the prescription, but not know what it is for?

Next, I was responsible to administer the medications. But first, I was expected by nursing practice standards to confirm the “7 rights” of medication administration: the right patient, drug, dose, route, time, reason, and documentation. Once this was confirmed, I had to provide the medication to the patient, and was responsible for sharing my knowledge of the common adverse effects of each.

Often, one of the following scenarios would ensue:

  • Patients would indicate they understood this and take the medication.
  • Patients would indicate this was the first time they had ever heard of the medication’s adverse effects. Some would even say “Oh that’s why I have x,y and z… I was wondering why that was happening!”
  • Some patients flat out refused to take the medication, once aware of the adverse effects.

More often than not, patients did not know the common adverse effects of their own medications.

How can this be? How can someone take a medication every day, refill the prescription, but not know the potential problems it can cause?

The longer I nursed, the more I paid attention to the fact that patients often had what appeared to be a laundry list of medications. Sometimes I didn’t know why my patient was taking so many meds, even after a thorough chart review. So, I started having conversations with patients for whom I was caring, to understand why this was happening.

I often asked something along the lines: “You appear to be taking a lot of medications. Have you ever talked to your primary care provider about reducing the dose or frequency of your medications? Have you ever discussed coming off them completely?”

9 times out of 10 the patient would say NO. Often they explained:

  • “Most of my meds were prescribed by another doctor and my own doctor won’t touch them!
  • “I would love to be off some of these meds – I take so many!”
  • “My meds are working, so why would I change that?”

How can this be? How can someone take a medication every day, refill the prescription, but never discuss reducing or stopping it with their provider?

While I appreciate that not every medication we start can be stopped, I do know that not every medication is started with the intention that a patient should take it forever (or at least until Death do them part).

Both nursing schools and medical schools teach that our care should be patient-centered. The College of Nurses of Ontario defines patient-centered care this way:

“Health Care Providers consider patients’ individual needs and preferences, and ensure patients are active participants in all aspects of their health care decisions.”

Does a patient taking a laundry list of medications, unsure of their indications and adverse effects, sound patient-centered to you? Does “just following doctors’ orders” sound like patient-centered care?

We need to ensure that our patients, including my future patients, are champions for their own health. As a recent nurse and future physician, I want to encourage us all to check in with our patients. Do they truly want to take all the medications now prescribed? Are there alternatives? Do they need them anymore? Do the adverse effects outweigh the benefits?

Just remember:

Deprescribing is patient-centered care.

Ashley Perreault, BScN is a MD Candidate – Class of 2024 at the Northern Ontario School of Medicine. Ashley opened a deprescribing workshop in Ottawa, Canada on April 21, 2022.

Do YOU have any thoughts about this issue?

We will consider posting brief responses if accompanied by name and affiliation and a completed ICMJE conflict of interest declaration available here:

  • Laura Chalfin
    Posted at 08:24h, 07 September Reply

    Our family practice now has a clinical pharmacist who can do much of what is advised in Ashley Perreault’s Blog post. The pharmacist is allotted about 90 minutes to deal with each patient, something that family physicians cannot do. It would be helpful if some specialists would indicate the recommended duration for prescriptions they initiate. For example, many anticoagulants are intended for a specified duration after a cardiac procedure, but this is not noted on the original prescription. In addition, anticoagulation recommendations are constantly changing.
    It’s not reasonable to expect a family doctor, every time one is asked to refill a prescription, to track down the original consultation report and calculate how long the patient has been taking the drug. Once more, this amounts to expecting the family doctor to be doing the specialists’ paper work.
    It would be interesting to learn other thoughts on how this issue could be addressed constructively.
    Laura Chalfin, MD
    Hornby Island, BC

    Dr. Laura Chalfin has no conflicts of interest to disclose.

  • Dianne Calder
    Posted at 09:53h, 07 September Reply

    I agree with you 100%. The challenge is convincing patients to trial a stop of a medication if an indication no longer there.
    Dianne Calder
    Alberta Health Services

    No conflicts of interest to declare.

  • Kathleen Potter
    Posted at 14:28h, 08 September Reply

    Great presentation Ashley.
    Thanks so much for your clear-eyed view on this. Like a voice from my bones, you are absolutely on the money concerning the way that people end up with a “laundry list” of medicines but often with no good understanding of what medicines they are taking or their actual purpose. This resonates very strongly with me, as a GP specialising in the care of people living in residential age care.
    Kathleen Potter MBChB, PhD, FRACGP, FRNZCGP
    Hokitika, New Zealand

    Conflict of interest declaration: Dr. Potter works with, and is as a member of the medication advisory committee for Ryman Healthcare, a private provider of long-term care in New Zealand. She states: “We have a firm focus on deprescribing.”

  • Raha Eskandari
    Posted at 06:33h, 23 September Reply

    Dear Ashley,
    That was a great presentation.
    As a hospital pharmacist working in a tertiary referral hospital in Iran, I often witness therapeutic duplication while taking medication history as part of the medication reconciliation process. I believe that this is another concern due to its potential to raise the risk of polypharmacy and its subsequent adverse effects to the patients.
    Sometimes therapeutic duplication is just an unintentional error due to a physician’s limited time that makes them unable to carefully review patient’s medication history. Sometimes it may come from different physicians writing different prescriptions for one patient and the tragedy is that none of them are aware of each other’s orders. In the latter case, the patient is often unaware of taking the same medication because of different brand names.
    Sometimes therapeutic duplication may be intentional with the aim of providing greater therapeutic effect by prescribing drugs from the same class; however this practice is not always based on evidence!
    From my point of view, best possible medication history and evidence-based practice ought to be considered by all healthcare professionals in order to enhance patient safety as well as quality of care.

    Raha Eskandari, Pharm. D
    CRDRC, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran

    No conflicts of interest to declare.

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