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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Screen Shot 2014-10-14 at 5.54.25 AMOne 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

7 comments

  1. I fully support your deprescribing. At one time I was a practicing consultant dietitian in long term care and would throw my arms up at physician orders for the 80 year old nursing home resident for a “cardiac diet” … What are you going to achieve with that? Furthermore; with the recent technology of personalized medicine why not genetically test long term care residents so we are prescribing meds that actually work for them? I bet that may also lead to deprescribing??

  2. As simple as this idea is – it is BRILLIANT! Amazing the power of a word = “deprescribe”. Whereas merely “stopping” a medication sounds mundane and passive – there is ACTION in the verb, “deprescribe” which empowers the health care provider to feel like they are truly taking a positive action. As per Dr. John – it is purely in the “mindset” – but it is the mindset that empowers us all. Actively deprescribing medications that our patients are taking (but do not truly need) may be the single most potent action we can take to make our patients better (as well as “feel better”, when those drug-induced adverse reactions go away). Clearly, judgment will be needed to determine IF a medication is or is not needed – but deprescribing those that aren’t truly needed may work wonders.

  3. The 7 pills initiative… This is my national healthcare plan. You get 7 pills. All of us. Go to a doctor and your on 7 meds already, well something has gotta go before adding that next one. Just admitted an extremely healthy 95/F to Cardiac Rehab today following TAVR, has been exercising for the last 50 years and is fit. Walks great. What has she been rewarded with for taking such good care of her self over the years? Pills, pills, and pills. 95y/o and has a remote health history of melanoma and that’s it, now thrown on a bunch of pills… The TAVR went great, now lets see if she can survive the pills….

  4. More than the word “deprescribe” (which I love), I particularly love the last paragraph where you say “…an opportunity to inject care back into healthcare.”

    Beyond whatever you are talking about, this idea of injecting care back into healthcare is a pervasive and recurrent theme of so many of your posts. This is perhaps the single most important thing that needs to happen in modern medicine. and the greatest contribution of your writings in my opinion.

  5. I’m sitting here looking at my pill box., 15 pills in the morning. 3 in the afternoon and 9 more in the evening, then one more injection every month. And beside that I have a defibrillator and a CPAP machine Before every doctor appointment I stand over it and ask myself what could be culled, especially at my annual physical. I would love it if a physician would look at it and tell me what to we should cut. I realize that I am not in the geriatric category that you are talking about, Most of the conditions that you talk about have been under control for more than a year, some 3-5 years. The control came mostly through exercise and diet. But my doctors are saying “We have this under control. Let’s not change anything.” How can I get off any of these medications?

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