2020; Volume 21, No 9, September
Under My Microscope
Dr. Tania Pastrana. Used with permission.
IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.
Deprescribing in Older People
Liacos M, Theresa Page A, Etherton-Beer C. Aust Prescr 2020; 43: 114-20. DOI: 10.18773/austprescr.2020.033
I wonder about the amount of medications that some patients are prescribed; in the palliative ward, we have to add prescription sheets to include all polypharmacy. This month, I came across a review by pharmacist Michelle Liacos et al. about deprescribing practices. The authors define deprescribing as the process of discontinuing drugs that are either potentially harmful or no longer required.
With medication, the adage “the more the better” does not apply. Patients who take more than five medications (polypharmacy) are “associated with an increased risk of adverse outcomes such as hospital admissions, falls, and premature mortality.” Polypharmacy also generates unwarranted costs for patients and the health care system. Additionally, “in older people with a severe life-limiting condition, such as advanced dementia or end-stage organ failure, the potential benefit of preventive medicines may not be realized due to the person’s short life expectancy and may not be the goal of their treatment.” Therefore, at least three ethical principles come into play.
The authors cite tools to support deprescription decisions. In palliative care, we aim to improve a patient's quality of life, sometimes by reducing their drug burden. We need to balance medication use by keeping necessary, beneficial medications while avoiding those that may be harmful.1 We already have evidence to support deprescribing approaches.2
Felton et al.3 suggest the acronym FRAME to guide conversations about deprescribing:
F: Fortify trust.
R: Recognize patient willingness or barriers to deprescribing.
A: Align deprescribing recommendations to goals of care.
M: Manage cognitive dissonance.
E: Empower patients and caregivers to continue the conversation.
References
1. Paque K, Elseviers M, Vander Stichele R, et al. Balancing Medication Use in Nursing Home Residents with Life-Limiting Disease. Eur J Clin Pharmacol 2019; 75(7): 969-977. DOI: 10.1007/s00228-019-02649-6
2. Lindsay J, Dooley M, Martin J, Fay M, Kearney A, Barras M. Reducing Potentially Inappropriate Medications in Palliative Cancer Patients: Evidence to support deprescribing approaches. Support Care Cancer 2014; 22(4): 1113-1119. DOI: 10.1007/s00520-013-2098-7
3. Felton M, Tannenbaum C, McPherson ML, Pruskowski J. Communication Techniques for Deprescribing Conversations #369. J Palliat Med 2019; 22(3): 335-336. DOI: 10.1089/jpm.2018.0669
Deprescribing is the process of discontinuing drugs that are either potentially harmful or no longer required. It can be achieved in older people and may be associated with improved health outcomes without long-term adverse effects. The risk of drug withdrawal effects can often be mitigated by carefully monitoring and gradually tapering the dose. Deprescribing should ideally be a shared decision-making process between the patient and the prescriber.
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Media Watch: The ICU & ACP
The COVID-19 pandemic has increased attention on end-of-life care in intensive care and broadened discussion about serious illness preparation and planning. The articles below are selected from Barry R. Ashpole’s weekly report, Media Watch.
Proactive Identification of Palliative Care Needs among Patients with COVID-19 in the ICU
Journal of Pain & Symptom Management | Online – 13 June 2020 – The palliative care (PC) needs of patients with COVID-19 and their families are profound and may not be adequately identified or addressed by traditional consultant referral systems. Given the potentially prolonged duration of the pandemic and the possibility of future patient surges, PC teams should consider implementing a process of proactive screening and outreach to settings in their hospitals with high need. If successful, such processes could extend beyond COVID-19, generating a new standard of practice and a small silver lining to the pandemic. DOI: 10.1016/j.jpainsymman.2020.06.008
Best Case/Worst Case: ICU (COVID-19) — A tool to communicate with families of critically ill patients with COVID-19
Palliative Medicine Reports | Online – 30 April 2020 – During the COVID-19 pandemic, critically ill patients have been...strictly isolated. In March 2020, palliative care clinicians at the University of Wisconsin were asked to bridge a gap in communication between patients' families and critical care teams, as bedside demands overwhelmed the teams’ capacity to provide consistent communication. In response, the authors adapted an established intervention to support daily conversations between clinicians and out-of-hospital family. DOI: 10.1089/pmr.2020.0038
MVP (Medical situation, Values & Plan): A memorable and useful model for all serious illness conversations
J Pain Symptom Manage | Online – 29 July 2020 –MVP is a sequential, fluid, iterative 3-step process for any serious illness conversation, resting upon three interrelated core communication skills: 1) seeking mutual understanding of the Medical situation, 2) exploring patient Values, and 3) defining a goal-concordant Plan.
Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)
Healthcare, 2020;8(3): E218. Research has documented substantial medical errors regarding the use or non-use of life-sustaining treatments in older persons. The author argues that the prevailing understanding and current practice of advance care planning perpetuates the problem and results in patients not receiving optimal patient-centered care. A new approach is posited: Advance Serious Illness Preparations and Planning (ASIPP). DOI: 10.3390/healthcare8030218
Media Watch is international in scope and distribution. View current and back issues here.