Ethical Decision-Making with Deprescribing for Older Adults
Physicians must consider multiple ethical issues when making decisions on deprescribing for older adults with dementia, a recent study found.1 In 2021, researchers surveyed 689 primary care physicians and asked them to consider situations in which a physician might decide to deprescribe. In one of the hypothetical cases, the medication could result in an adverse drug event; in the other hypothetical case, there was no evidence of benefit. The physicians then ranked factors related to ethical and pragmatic concerns. In both of the hypothetical cases, physicians reported these as the two biggest barriers to deprescribing:
- that the patient or family reported benefit from the medication, so the physicians worried that deprescribing could worsen symptoms;
- that the medication had been prescribed by another doctor.
Patients are taking more prescriptions in large part because of seeing multiple specialists, most of whom are reluctant to discontinue medications prescribed by a different provider, says J. Russell Teagarden, DMH, MA, a medical ethicist who has worked in community pharmacy, hospital pharmacy, and in medical affairs in pharmacy benefits administration. From the standpoint of an individual patient, ethical deprescribing “comes down to a straightforward analysis of risk and benefit,” says Teagarden. With older patients, the risk/benefit ratio for the same drug can change over time and has to be re-evaluated regularly, adds Teagarden.
Unnecessary prescriptions are ethically concerning because they could harm individual patients. However, the situation also affects healthcare more generally. “What I don’t hear mentioned much in this context is, more broadly, the societal element,” says Teagarden. Pharmacies are overwhelmed by the sheer number of prescriptions being filled, not all of which are needed. This is happening amid growing concerns about the high prevalence of burnout among pharmacists.2 “There is an ethical rationale to reduce the volume of prescriptions to take pressure off the pharmacies, allowing them to serve people in need better,” asserts Teagarden.
Ideally, the work of deprescribing would occur mainly in the outpatient setting, says Teagarden. This would require patients to have good relationships with primary care providers (PCPs) and for PCPs to have time for in-depth review of prescriptions. In reality, healthcare providers are pressed for time and might be seeing the patient for the first time. “Where do you get that capacity? The current system of healthcare delivery is set up to work against that,” says Teagarden.
At some skilled nursing facilities, pharmacists historically reviewed medications of residents regularly. “Invariably, those populations are going in and out of hospitals, are put on drugs that are very specific to the hospitalization, and are discharged on those drugs,” says Teagarden. Some drugs used for the hospitalization get continued at the nursing home. Pharmacy reviews resulted in some of those drugs being discontinued. Similar efforts are made at some hospitals, where pharmacists perform medication reconciliation. The focus is on patient safety and drug interactions — for medications the patient is taking currently, medications that are given at the hospital, and medications the patient will be prescribed on discharge. However, these efforts are not quite the same as having a designated healthcare provider review the patient’s medications with a central focus on deprescribing unnecessary medications, says Teagarden.
“On an ethical level, it’s easy to get on a high horse and say, ‘People are on too many drugs and we need to take them off some of them.’ But it requires careful consideration,” Teagarden underscores. Some drugs require tapered withdrawal, and it is necessary to carefully consider the patient’s history and reason for each prescription. In years past, community pharmacists typically did this to some degree by calling the physician if the patient was taking medications the pharmacists felt might be unnecessary. “Pharmacists would call the doctor, talk it over, and get it fixed,” says Teagarden. “But that takes time — and that’s the one thing that people in healthcare don’t have.”
- Norton JD, Zeng C, Bayliss EA, et al. Ethical aspects of physician decision-making for deprescribing among older adults with dementia. JAMA Netw Open 2023;6:e2336728.
- Dee J, Dhuhaibawi N, Hayden JC. A systematic review and pooled prevalence of burnout in pharmacists. Int J Clin Pharm 2022;45:1027-1036.
Physicians must consider multiple ethical issues when making decisions on deprescribing for older adults with dementia, a recent study found.
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