Nuanced Conversations and Deprescribing
By Katherine O’Brien
Deprescribing — the planned and supervised process of dose reduction or stopping of medication that might be causing harm, or no longer be of benefit — can present challenges for clinicians and their patients if the process is not accompanied by the right kind of conversations.
In order for deprescribing to be successful, it’s essential physicians understand the values of their patients and align deprescribing with the patient’s priorities, says Dr. Ariel R. Green, M.D., Ph.D., M.P.H., the lead researcher of the “Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults” survey study. Authors of the study, which focuses on understanding the language that improves the uptake of deprescribing, conclude that patient involvement is key, as is framing discussions in language that is acceptable to patients. “Going in there with a rigid approach … may ultimately turn off many patients, so we need to understand their experience and really express that this is a shared decision,” she says.
The study, published in JAMA Network Open in April 2021, presents respondents with two scenarios: one describing a statin and, the other, a sedative-hypnotic used for insomnia. In both vignettes, the most preferred phrase to explain deprescribing focused on the risk of side effects. Doctors need to convey to patients that all medications carry potential side effects — that even if a medication could improve one problem, it could make three others worse, says Dr. Green, an Associate Professor of Medicine at the Johns Hopkins University School of Medicine.
With the sedative, another phrase that resonated was, “This medicine is not good for you in the long run; let’s work together to slowly reduce the dose and get you off it over time.” As she points out, “I think patients want to hear that they will be supported in deprescribing, that they have a say in the matter of what they put into their bodies.”
There were also some surprises about what didn’t resonate with patients. Researchers were surprised the least preferred statement in the statin vignette was, “Taking this medicine requires extra effort for you,” says Dr. Green, who notes geriatricians place importance on helping patients avoid treatment burden. “It’s so complex, but I think that [the] finding suggests that many patients are willing to experience burden to prevent adverse outcomes in the future.”
In general, says Dr. Green, the findings show considerable variability — no single phrase was always chosen as the most or least preferred — which underscores the importance of focusing on health outcomes that patients value. When caring for patients with life-limiting illnesses, for example, doctors should ascertain whether they’d prefer to focus on comfort or on preventing future health conditions, she says. As well, in these cases, physicians need to frame deprescribing as a positive step to improve quality of life, not a withdrawal of care, she adds. Instead of saying something like, “you’ve had a good, long life, we can stop some of these preventative medicines,” it’s better to reframe the phrase as, “these medications could take years to have an effect, and I think we should focus on what will help you feel better or function better right now.”
As with other health issues, for deprescribing to succeed, patients need to be open to changing behaviours, points out Dr. Green, who suggests linking the conversation to health concerns, such as a decline in energy or cognition. She also advises to keep an eye out for openings that could segue into a talk about deprescribing. For example, patients who have recently been hospitalized for a fall or who complain about the number of pills they must take might be receptive to a conversation about reducing medication.
Keep in mind these conversations tend to be more nuanced — and potentially more time-consuming — than typical patient-doctor interactions, she points out. As well, in some cases, doctors may have to initiate conversations about deprescribing over the course of many visits. “Deprescribing is not a one and done thing — it will take time, and you need to offer support and offer alternatives, including non-pharmacologic ones.”