Evidence suggests that patients with a prognosis of less than one year are burdened by polypharmacy and take an average of 11.5 medications per day. Deprescribing is the process of tapering or stopping drugs; the aim is to improve patient outcomes near the end of life by minimizing polypharmacy.
While barriers to deprescribing include a lack of clinician confidence in deprescribing skills and a fear of triggering psychological distress by discontinuing familiar medications, research indicates that patient-clinician trust can endure when deprescribing is done well.
Before the deprescribing conversation, clinicians should identify deprescribing-eligible medications via chart review. They should include those medications where:
- the benefits no longer outweigh the adverse-effect risk,
- the time-until-benefit exceeds the anticipated prognosis, and/or
- the treatment target no longer aligns with the patient’s goal of care.
The ‘FRAME’ acronym for deprescribing conversations.
– Fortify trust. Patients often have strong perceptions about medication changes. Insensitive deprescribing advice can lead to mistrust, feelings of abandonment, or a sense of futility of previous compliance.
- Recognize patient willingness or barriers to deprescribing. While clinicians are often worried that patients may be psychologically attached to their medications, evidence suggests that patients are also greatly concerned and burdened by polypharmacy. In one cross-sectional study, up to 98% of geriatric patients reported willingness to stop one or more of their medications.
- Align deprescribing recommendations to goals of care. Deprescribing recommendations will be better received if they align with the patient’s medical goals and values.
- Manage cognitive dissonance. Cognitive dissonance occurs when a person experiences mental discomfort from two or more simultaneous contradictory beliefs, ideas, or values. Often patients or caregivers struggle with cognitive dissonance after a formal deprescribing recommendation is given, because they associate medications with making them better, not putting them at risk for harm. Cognitive dissonance must be recognized and addressed.
- Empower patients and caregivers to continue the conversation. Like advance care planning, deprescribing conversations should not be limited to one point in the care continuum. Subsequent conversations are often needed to decrease unnecessary pill burden effectively.
See reference for more information.
Adapted from Felton M et al. Communication techniques for deprescribing conversations. Palliative Care Network of Wisconsin. Fast facts and concepts #369. Internet. Accessed on December 27, 2019.