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Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia

Norton JD, Zeng C, Bayliss EA, Shetterly SM, Williams N, Reeve E, Wynia MK, Green AR, Drace ML, Gleason KS, Sheehan OC, Boyd CM. Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia. JAMA Netw Open. 2023 Oct 2;6(10):e2336728.

Deprescribing is challenging. While a number of qualitative studies have explored clinician barriers to deprescribing, relatively little work has been done to quantify clinician’s perceptions of the relative importance of these barriers. The Norton et al. study, conducted from January 15 to December 31, 2021, was a cross-sectional national survey aiming to investigate how primary care physicians prioritize ethical and pragmatic factors when making deprescribing decisions for older adults (aged 65+) with moderate dementia. The survey sought to identify the biggest and smallest barriers to deprescribing in situations where ethical dilemmas may arise by using best-worst scaling methods to rank nine influencing factors. In doing so, the study aimed to inform clinician education on medication management and deprescribing for this vulnerable population, including the need to address ethical complexities and pragmatic challenges.

The cross-sectional study involved 3,000 U.S. physicians randomized into equal groups to receive one of two survey versions exploring deprescribing scenarios in older adults with moderate dementia – one involving the potential for an adverse drug event if the medication is continued and the other lacking evidence of benefit in this patient population. The survey, “Understanding Physician Deprescribing Decisions,” comprised 24 questions and utilized the best-worst scaling methods to assess perceived barriers to deprescribing. Demographic information was obtained from the AMA database. The scenarios included factors related to ethical principles and biomedical considerations.

The final study sample included 890 U.S. physicians (35.0% response rate) who were predominantly male (57.4%) with a mean (SD) of 26.0 (11.7) years since graduation and were presented with scenarios involving increased risk of adverse drug events (ADE) or limited medication benefit. In both scenarios, “patient and family reported symptomatic benefit from the medication” (related to the ethical principle of autonomy) emerged as the most important barrier to deprescribing. Physicians ranked medications initiated by others (ethical principles of autonomy and nonmaleficence) as the second most crucial barrier to deprescribing in either scenario, with financial considerations (ethical principal of justice) ranked as the least important. This study highlights ethical complexities and pragmatic challenges in making deprescribing decisions with patients with moderate dementia, emphasizing the need for evidence-based guidance and clinician education. Strengths included using best-worst scaling methods and focusing on a relevant patient population, while limitations involved a moderate response rate, potential pandemic influences, and some missing responses in the analysis.

Author Jonathan Norton reflects on how to improve deprescribing practices in future clinician education:

“Healthcare providers are primarily taught how to start medications and not necessarily how to stop them. We hope the use of the ethical and pragmatic lens to medication management highlights the importance of shared decision making and communication to achieve goal-aligned care for patients with dementia. We know many physicians support deprescribing and optimizing medication regimens to maximize benefits for their patients, but report needing guidance to make those decisions. While more research is needed to develop the clinical guidance and clinician education on deprescribing, we recommend some talking points to get the conversation started for healthcare providers who are seeking to address deprescribing opportunities for patients living with dementia:

  • Have you talked to your patients about the symptoms they are most concerned about?
    • Phrase to try: “We will review how you are feeling and your medications to determine if all of them are still needed.”
  • Have you talked to your colleagues about stopping a medication they prescribed?
    • Phrase to try: “Let’s consider the patient’s primary goals for this year and how we could adjust their medications to support those goals”
  • Have you asked your patients if money is an issue when it comes to their medication?
    • Phrase to try:“I would like to talk to you about the cost of your medication(s). Would that be okay with you?”

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