Engaging patients: your words matter

Many of us have raised the issue of stopping a medication and been met with hesitance from a patient. Patients might be fearful of the negative effects of stopping a medication or be worried about missing out on perceived future benefits of the medication.1 This is often justifiable as the option to back off in the future might not be discussed when a medication is started. When it comes to engaging patients in deprescribing, what we say, and how we say it, matters. In this column, we look at engaging patients in deprescribing decisions and planning. Start a conversation One of the first things to think about is how we introduce and frame the concept of “deprescribing.” We would rarely if ever use the term deprescribing when talking to a patient. If you have identified a possible deprescribing opportunity, one suggested approach is to introduce the idea of deprescribing simply as a “conversation about options.”2 One option may be to continue a medication, whereas another option might be to stop a medication. The goal is to explore different aspects of the decision (e.g., pros and cons of stopping or reducing, cost/convenience), explore patient preferences, and find the best choice for the individual.3 Talk about why stopping or reducing a medication is an option Patients need to understand the rationale for deprescribing.1 If you are raising stopping or reducing a medication as an option, explain why this is being considered.1 The specific rationale will depend on the individual patient, medication and context. For example, for a benzodiazepine, the central consideration may be concern about actual harm or risk of future harm. In contrast, for a potentially unnecessary long-term proton pump inhibitor (PPI), the main reason for stopping would be that the medication is no longer needed. Researchers and clinicians have identified some helpful phrases and language to start or engage in a conversation (Box 1).4-6 Patient-directed resources from https://deprescribing.org and the Canadian Medication Appropriateness and Deprescribing Network can help to engage patients in a conversation. Involve patients in decisions Provide patients with an opportunity to ask questions about options and to share their preferences and priorities.5,6 For many deprescribing decisions the best choice for an individual depends on what is important to them.7 For example, a patient taking gabapentin for diabetic neuropathy may be bothered by dizziness and drowsiness caused by this medication, even though it is helping their pain. In this situation, the patient may be more concerned about side effects than any benefits in pain management, and discontinuation or dose reduction may be the best choice. Patients may need to time to think about their options. Deprescribing is a process; a decision can be revisited later if patients need more time. Involve patients in the plan Work together with patients to develop deprescribing plans that fit for them. This includes the method of deprescribing, the method of follow-up, and the frequency of follow-up.1 Discuss the deprescribing methods available such as tapering (including the tapering rate and schedule) or abruptly stopping. The best plan will depend on the medication and the individual person. For example, a patient on trazodone 100 mg qhs for insomnia for 10 years may prefer a slow taper over several months, whereas a patient who has taken trazodone 50 mg qhs for one month may want to pursue a faster taper. Explain to patients that a medication can always be restarted or increased back to its original dose if withdrawal symptoms occur or the underlying condition returns.1 One suggested approach is to frame deprescribing as a “pause and monitor,” reminding patients that stopping or dose reduction is a trial, and they will be monitored closely throughout the process.2 Discuss what to expect upon stopping or reducing (e.g., what symptoms to watch out for) and have a plan for what to do if symptoms come back. For example, if dose reduction of a PPI is being considered, explain that rebound upper gastrointestinal symptoms may occur but are usually not serious and will go away after a few days or weeks.8 If rebound symptoms do occur, have a plan for treating them, such as taking an antacid as needed.8 It may also be helpful to agree on a threshold for when to restart the medication (e.g., for a PPI, if symptoms are so severe that they interfere with sleep or usual activities).8 Ask patients about their preferred frequency and method of follow-up. Patients value knowing they will be supported and monitored through the process.1 The frequency and method of follow-up will depend on the individual medication and patient preferences. Communicate your conversation and plan with other relevant healthcare team members. Pharmacists are well-positioned to have conversations about medication options and to conduct follow-up and monitoring.9-11 Wade Thompson is a pharmacist and researcher working to ensure older persons are taking medications that are necessary, effective, safe, and consistent with their healthcare goals and treatment preferences. He is an assistant professor in the Department of Anesthesiology, Pharmacology and Therapeutics in the Faculty of Medicine at the University of British Columbia. He is an investigator with deprescribing.org and a member of the Therapeutics Initiative, and works clinically as a pharmacist in long-term care. References: Reeve E, To J, Hendrix I, et al. Patient barriers to and enablers of deprescribing: a systematic review. Drugs Aging 2013;30:793-807. doi:10.1007/s40266-013-0106-8. Farrell B, Mangin D. Deprescribing is an essential part of good prescribing. Am Fam Physician 2019;99(1):7-9. (accessed July 26, 2023). Jansen J, Naganathan V, Carter SM, et al. Too much medicine in older people? Deprescribing through shared decision making. BMJ 2016;2893:i2893. doi:10.1136/bmj.i2893. Green AR, Aschmann H, Boyd CM, et al. Assessment of patient-preferred language to achieve goal-aligned deprescribing in older adults. JAMA Netw Open 2021;4(4):e212633. doi:10.1001/jamanetworkopen.2021.2633. Agency for Healthcare Research and Quality. The SHARE approach - essential steps of shared decision-making: Expanded reference guide with sample conversation starters; 2020. (accessed July 5, 2023). Elwyn G, Durand MA, Song J, et al. A three-talk model for shared decision making: multistage consultation process. BMJ 2017;359:j4891. doi:10.1136/bmj.j4891. Elwyn G, Frosch D, Rollnick S. Dual equipoise shared decision making: definitions for decision and behaviour support interventions. Implementation Science 2009;4(1):75. doi:10.1186/1748-5908-4-75. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors evidence-based clinical practice guideline. Can Fam Physician 2017;63(5). (accessed July 26, 2023). Trenaman SC, Kennie-Kaulbach N, d’Entremont-MacVicar E, et al. Implementation of pharmacist-led deprescribing in collaborative primary care settings. Int J Clin Pharm 2022;44:1216-21. doi:10.1007/s11096-022-01449-w. Duncan P, Duerden M, Payne RA. Deprescribing: a primary care perspective. Eur J Hosp Pharm 2017;24(1):37-42. doi:10.1136/ejhpharm-2016-000967. Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med 2014;174(6):890-8. doi:10.1001/jamainternmed.2014.949.

Engaging patients: your words matter

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WADE THOMPSON

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