What does it take to be effective at deprescribing (discontinuing or reducing the dose of) unnecessary or harmful medications? It is a combination of knowledge and communication skills, according to self-proclaimed “rogue deprescriber,” Dr. Cara Tannenbaum.
Tannenbaum is a Professor on the faculties of Medicine and Pharmacy at the University de Montreal in Quebec, Canada, and the Director of the Canadian Deprescribing Network.
In a recent Grand Rounds presentation at the Brigham and Women’s Hospital, Tannenbaum showed doctors and trainees some strategies, tools, and communications techniques to engage patients in deprescribing.
How to FRAME deprescribing conversations
For successful communication about deprescribing, Tannenbaum suggested using the acronym FRAME:
- Fortify trust. Establishing a trusting relationship with patients and families and understanding patients’ health and life goals are essential before initiating deprescribing conversations
- Recognize patient willingness or barriers to deprescribing. Understand that many patients are open to deprescribing medications, but deprescribing can also seem scary. You can say, “Is this a good time to ask you how you feel about your medications?” and other open-ended questions to gauge how they feel about the medications they are taking.
- Align deprescribing recommendations with goals of care. Tailor your deprescribing recommendations to the patients’ previously discussed health and life goals. For example, you can say, “Thank you for telling me that you want to spend more time playing with your grandchildren. I want to discontinue your metoprolol as this medication can cause fatigue as your heart rate has been low lately.”
- Manage cognitive dissonance. Understand that patients have been told for many years that medications keep them healthy, and may feel uncomfortable discontinuing them.
- Empower patients and caregivers to continue the conversation. Deprescribing does not need to happen all in one visit. Make sure to schedule subsequent visits to address all of your patients’ medications, or encourage patients to visit their other clinicians to ask about deprescribing specific drugs.
How do you bring up deprescribing?
It can be difficult for clinicians to begin conversations with patients about deprescribing, because patients may have been told for years that their medications are keeping them healthy. Patients and families may think that clinicians are “giving up on them” by suggesting discontinuing medications.
“For the most part, everyone is quick to identify which medication shouldn’t be there, but there’s greater reluctance to act and deprescribe the medications.”
Cara Tannenbaum
Tannenbaum suggested several different ways to bring up the subject while addressing patients’ concerns. One way is to be direct and say, “I don’t think it’s good for you to be on this many medications. I want to reduce this to a more manageable number of medications for you.” You can also use body language to convey surprise at the number of medications someone is taking, to show that you are concerned. This direct approach may seem scary, but it’s important to know that the vast majority of older patients would be willing to deprescribe if their doctor said it was possible.
Another way is to take an indirect approach, by asking about a specific medication or symptom. For example, a clinician could ask, “Did you know you’re taking a sleeping pill? How is your sleep?” Then bring up potential side effects of the medication: “Did you know this medication affects your memory and balance? I would like to try switching you to non-drug therapy.” Patients might not know about the risks. When Tannenbaum tells patients about drug side effects, she often hears patients say, “No one ever told me that!”
A third strategy is using an emotional appeal and say, “I’m worried about the number of medications you are taking” or “I wouldn’t let my mother walk out of the office with all of these meds today.” This shows how you care about your patient and conveys the harms of medication overload.
Lastly, if you are not yet comfortable talking with your patient about medications, you can hand them the EMPOWER brochure or other written materials about medication harms. This brochure has been shown to reduce the use of benzodiazepines in older adults by 22%.
“There’s a polypharmacy epidemic. Are we going to accept it? Or are we going to be “unreasonable” about accepting it.”
Cara Tannenbaum
When is the right time to deprescribe?
Clinicians who want to deprescribe may wonder, when is the right time to discuss medications with patients? Tannenbaum said there is no wrong time to deprescribe; deprescribing conversations can be effective when conducted upon admission, discharge, or another time.
However, she noted that an adverse event or new diagnosis are both good times to discuss medications. If a patient has a fall or other serious side effect, it is important to look at their medications right away to see whether one of their medications could have been the cause.
For patients facing a new diagnosis, especially one that changes estimated life expectancy, patients’ goals will often change, so a reevaluation of their medication list is necessary. While clinicians may think that deprescribing conversations would be less of a priority in this situation, Tannenbaum noted that cancer patients with polypharmacy are more likely to experience falls and other side effects, and may find it more difficult to adhere to their cancer medications, compared to cancer patients taking fewer drugs.
Lastly, Tannenbaum urged clinicians to be brave, even though deprescribing can seem scary. “There’s a polypharmacy epidemic. Are we going to accept it? Or are we going to be ‘unreasonable’ about accepting it,” she said. “Dare to be the leader that others follow!”
