Hospice Pharmacy Insights August 2020

In a JAMA Neurology article in April 2020 they recognized that “The emerging field of deprescribing—the systematic process of discontinuing drugs where harms outweigh benefits in the context of an individual patient’s values—seeks to rescue patients and clinicians alike.” In a query of prescribing and deprescribing the ratio of hits was 120 to 1. As you can see good clinical information on deprescribing is scarce at best.

As hospice professionals we have been deprescribing for years because many of our patients come to hospice on 10-20+ medications per day. Many of those patients are not only elderly but are often frail and debilitated as well. These factors significantly increase the risk for drug/drug interactions, adverse events, etc. This makes one of our first tasks to review medications to determine which are either doing nothing or are causing harm. Then to devise a plan to appropriately deprescribe those medications.

With this in mind, we have been keeping a close watch on the clinical research for anything that supports and enhances our clinical practice of deprescribing. Recently I came across a research article, “A concept analysis of deprescribing medications in older people” (see below for full citation). As a nurse I appreciate algorithms and stepwise processes that assist me in being a better clinician and provide better care to my patients. In this research article I found a couple of multi-step processes that I hope you will find useful as you consider deprescribing for your patients.

“Deprescribing is a variation from the status quo and is thus perceived as an active intervention. This perception of deprescribing as an active intervention differentiates it from simply omitting a medication without careful consideration. Structured and iterative processes involving multiple steps underpin deprescribing interventions. The steps are often presented in a linear fashion, but it is an iterative process. In ‘Deprescribing: a guide for medication reviews’, we recently described the multi-step, co-operative process to deprescribing (Steps One to Five below). The BMJ recently published a review on the need for health professionals and consumers to discuss deprescribing as a shared decision-making process. In this review, they outlined the steps A, B and C below, which are needed to discuss deprescribing with consumers to facilitate a shared decision. The combined steps from these papers detail the process.”