Australian Doctor 4th August 2023 AD 4th Aug Issue | Page 47

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If a patient is not taking a medication , this could indicate withdrawal of their consent to take it . Explain the risks and benefits of this decision , but do not prescribe the medication if the patient still does not want it .

If a patient is not taking medication because of difficulty with access to doctors or pharmacists , or difficulty opening containers or not remembering to take it , this requires a different response . If they have not been taking it and there are no obvious adverse consequences , this is evidence that they may be alright without it . Also consider the risks of inadvertent double dosing as well as forgetting to take the medication .

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UNKNOWN INDICATION In this situation , ask yourself what condition this medication is treating , why it is being used , what problem it is trying to solve and what the goal is for its use ? Sometimes the answers are not clear , and a diagnosis may be erroneously made retrospectively or presumptively , because of a particular medication . For example , concluding that a person on risperidone has a mental illness or valproate is being used to treat epilepsy . Also consider whether the original diagnosis was sound .

If the indication is unclear , ascertain this as far as reasonably possible ; ask the patient or their family if anyone remembers when and why the medication was started ; seek information from the previous prescriber ; refer to a hospital discharge summary if appropriate ; and seek information in previous specialist letters or from the specialist .

The more the patient knows about their medication , the easier it is to collect this information ; another benefit of involving patients in their medication management and healthcare decision-making .

Where the indication remains unclear , it is reasonable to consider if there ever was an indication . Many indications for initiating medication are temporary but the medication is continued indefinitely . A rational way to proceed is discussing this with the patient and deprescribing , with monitoring for emerging problems .

GOALS OF CARE When a person ’ s life circumstances and goals change then the need for medication may also change . For example , when someone is nearing the end of their life and there is a deliberate change of focus to symptom management and quality of life , rather than prolonging life , this is a clear opportunity for meaningful goal-driven deprescribing . Re-examine the indication for each medication . Preventive medications , such as statins and bisphosphonates , are often prescribed up to the end of life , despite altered goals of care and the unlikely benefit to the individual . 8 , 20 A 2015 randomised trial established that there was no difference in mortality rates between those continuing statins and those deprescribed statins in patients with a life expectancy of less than 12 months , and quality of life was significantly better in the deprescribed group . 21

Also review antihypertensives and hypoglycaemics in those with life-limiting conditions . In a situation where a patient with a malignancy or other condition is losing weight , eating little and

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Figure 4 . Multiple medications .

A

B

Figure 5 . Multiple handwritten prescriptions . A . Section of a prescribing sheet .

This shows the prescriptions of three different attending doctors . B . Sample of a medication list .

Section of the oral medication that was paused for the day of the surgical intervention .

declining further treatment , they may be happy to hear there are unlikely to be consequences from stopping certain medications ; stopping some medications may even improve appetite and reduce adverse effects . 19 In addition to altered goals of care , the weight loss may have partially resolved issues of elevated cholesterol , blood sugar

Hartel M , et al . High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process . BMC Health Services Research 2011 11:199 / CC BY 2.0 / bit . ly / 3fPPXyt

and blood pressure . When discussing deprescribing options with these patients , reassure them that medications for pain relief and hypnotics will be available as required . 8

Patients who are frail or have advanced dementia or whose weight is decreasing for other reasons may similarly benefit from deprescribing . An open conversation about their changed condition and current goals of care is an opportunity to initiate this process . Most people recognise the importance of comfort and optimising quality of life ; these patients and their caregivers may appreciate a discussion regarding the optimal use of medications and reducing overall medication burden .

Figure 3 . Gout .

Where a person is frail or has significant symptoms , identifying these may be helpful in deprescribing , for example , “ You are getting unsteady / constipated / confused , and some of your medications may be making that worse . Let ’ s see what we think you can stop taking .”

AGED CARE HOMES

THE environment in RACFs can hinder deprescribing with patient ( polypharmacy and morbidity ) and prescriber factors ( multiple prescribers , poor communication and little time for consultation ) coming into play . 3 , 15 A major barrier to deprescribing anticholinergic and sedative medication in RACFs is devolving responsibility , that is , the passing of blame and responsibility to other health professionals . 17 Other barriers include nursing and care staff perceptions that medication is necessary , poor understanding of medication harms and resistance from residents and family . 12 An absence of clinical history on admission , fear of symptom reappearance and the perception that deprescribing equates to giving up on residents ’ care can also

3 , 15 , 17 inhibit deprescribing efforts .

Mindless rollover of medications on represcribing is easy as opportunities to talk to patients or their families are not presented , sought or not taken ( see figure 6 ).

Remember that the same rights to autonomy and making one ’ s own