To deprescribe…Adding a new verb to the language of doctoring

What follows is my most recent editorial in the Journal of the Kentucky Medical Association. It is reposted with permission.

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One day every month, my wife Staci, a hospice and palliative care physician, goes to see an elderly woman in the nursing home. The routine has gone on for years, which is surprising because the woman was admitted to the home with terminal diagnoses. But this patient didn’t die; she keeps living, month after month. “How is she?” I often ask. “She is fine. She eats, drinks, moves around in her chair and doesn’t have the frowny face of pain.”

How did a hospice doctor achieve such longevity and well being for her patient?

“I took her off almost all her medication, except a small dose of a pain reliever. Old people (like her) need food, and drink, and pain relief, not pills.” Staci says.

This case introduces an important new action verb in doctoring–to deprescribe. As modern medical technology advances, and people live longer but with more chronic diseases, the act of deprescribing has never been more relevant.

Let’s start with the act of prescribing, which lies at the core of what doctors do to help patients. Sadly, these days, most of what we advocate for are chemical modulators of body systems—pills. It doesn’t have to be this way; we could authorize smarter eating habits, more exercise, sleep hygiene and stress management strategies. But these are hard, and pills are easy. So it is then; in the name of health, patients, especially the elderly and infirmed, end up taking lots of pills.

If you work in a hospital you live the bleak statistics of over- and mis-prescribing. The FDA reports that adverse events from drugs have tripled in the last decade, with more than 117, 000 deaths in 2013. Hospital and emergency room visits due to adverse drug reactions number in the millions and up to one in six hospital admissions of older adults occur because of an adverse drug reaction. Older adults are especially vulnerable to poly-pharmacy and pill burden. As patients age they accumulate chronic diseases, organ function wanes, and drug clearance declines—a perfect storm for adverse drug reactions.

The list of medication harm is a long one. In the last month alone, I’ve seen patients with…a fractured hip due to low blood pressure from vasodilators, bleeding due to over-anticoagulation, confusion from diuretic-induced hyponatremia, cardiac arrest from QT-prolonging antibiotics, and 1:1 atrial flutter from an antiarrhythmic drug used to treat (previously) asymptomatic atrial arrhythmia.

So here is my proposal: Rather than just prescribe, I would propose that we, the healthcare community, collectively embrace and promote the action verb, deprescribe.

I know what you may be thinking: rarely is it a good idea to substitute a big word, deprescribe, when a small one, like stop, would do.

But deprescribing is more than just stopping a therapy. It’s more than just an action; it’s a way of thinking, a mindset. It brings to the fore another important verb (and noun)…need. What do patients need? And who determines this need? How do needs change over time?

For instance, does an 80-year-old with multiple problems and a prognosis measured in months to years need a cholesterol-lowering medication? Does a 74-year-old with Parkinson’s disease need a “perfect” blood pressure of 120/80? In my field of electrophysiology, a common opportunity to reassess need occurs when a patient with an ICD (internal cardiac defibrillator) comes for generator change. In the intervening years since implant, many things might have changed—the patient’s goals for care, accumulation of competing causes of death, improvement in cardiac function–such that deprescribing ICD therapy is our duty.

I know it’s not easy to embrace deprescribing. It goes against the culture of what we were taught: diseases need treatment. The problem, though, is that we aren’t treating diseases, we are treating people. So it’s complicated; it’s all connected. And things change over time. What was once a useful drug, one that relieved an important symptom or moved a relevant surrogate, can become harmful.

There will be barriers and pitfalls to the mindset of deprescribing. Chronologic age is not physiologic age—so there isn’t an age threshold. Some medications require weaning rather than abrupt stopping. Also, patients (and doctors) can grow attached to the association of living and taking medicines. But association is not causation.

Perhaps the biggest barrier to deprescribing is that it requires caregivers to face the certainty of end-of-life. This is where the going gets tough, for generalists and specialists alike. It’s not easy to think and talk about death and dying with our patients. But if we, as health professionals, won’t do it, who will?

The act of deprescribing offers an opportunity to inject care back into healthcare. Let’s embrace the idea together. Please help me add the new verb to our language.

JMM

Reference:

From Medscape: People’s Attitudes, Beliefs, and Experiences Regarding Polypharmacy and Willingness to Deprescribe