06 Sep 2022 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 10^th 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?

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