Background:  Evidence suggests that patients with a prognosis < 1 year are burdened by polypharmacy and take an average of 11.5 medications per day (1). Deprescribing is the process of tapering or stopping drugs, aimed at improving patient outcomes near the end of life by minimizing polypharmacy (see Fast Fact #321) (2). Barriers to deprescribing include a lack of clinician confidence in deprescribing skills and a fear of triggering psychological distress from the patient by discontinuing familiar medications (3,4). Research indicates that, fortunately, patient-clinician trust can endure when deprescribing is done well (5). This Fast Fact offers a deprescribing communication framework for leading these conversations.

Before the Deprescribing Conversation:  Clinicians should identify deprescribing-eligible medications via chart review (see Fast Fact #321).  Eligible medications include those where: a) the benefits no longer outweigh the adverse-effect risk (e.g. progressive renal failure) b) the time-until-benefit exceeds the anticipated prognosis; or c) the treatment target no longer aligns with the patient’s goal of care.  

The ‘FRAME’ acronym for leading deprescribing conversations:  

F – Fortify trust: Patients often have strong perceptions from medication changes.  Callous deprescribing advice can lead to mistrust, feelings of abandonment, or a sense of futility of previous compliance.  Palliative care providers must first establish a trusting relationship with the patient and/or caregiver in which they understand the medical goals of care prior to initiating deprescribing conversations (6).  

R – Recognize patient willingness or barriers to deprescribing: While clinicians are often worried patients may be psychologically attached to their medications, evidence suggests patients are also greatly concerned and burdened by polypharmacy. In one cross-sectional study, up to 98% of geriatric patients reported willingness to stop one of more of their medications (7).

• Incorporate open-ended questions like: “Do you feel that you are taking too many, too little, or just enough medications?” or “Do you feel your medications are inconvenient to take? Which ones?” The Revised Patients’ Attitudes Towards Prescribing (rPATD) is a 15-part validated questionnaire which aims to gain a better understanding of patients’ or families’ beliefs and barriers to deprescribing and the effect various medications have on quality of life (8). rPATD questions can be accessed and then modified into relevant open-ended questions to gauge willingness and barriers to deprescribing (8).
• Motivational Interviewing: this is an evidence-based communication strategy involving a conversational, patient-centered history-taking approach which is utilized over multiple clinic visits (see reference #9 for more information) (9,10). It is meant to gauge a patient’s willingness or ambivalence to make a clinically recommended behavioral change and then empowering a commitment toward that change (9-14). Motivational interviewing has been shown to be useful in leading many types of palliative care conversations, including deprescribing (13-14). When used for deprescribing, it should involve four key principles: 1) Empathetic listening to any expressed barriers; 2) Determination of the patient’s stage of willingness to pursue deprescribing; 3) Using clinical discrepancy if resistance to deprescribing develops; 4) Empowering self-efficacy by noticing even small incremental changes.  

A – Align deprescribing recommendations to goals of care:  As with any clinical scenario, deprescribing recommendations will be better received if they align with the patient’s medical goals and values (10). “Thank you for telling me that you want to spend more time gardening. I want to discontinue your metoprolol as this medication can cause fatigue as your heart rate has been low lately.”

M – Manage cognitive dissonance:  Cognitive dissonance occurs when a person experiences mental discomfort from two or more simultaneous contradictory beliefs, ideas, or values. Often patients or caregivers struggle with cognitive dissonance after a formal deprescribing recommendation is given because they associate medications with making them better, not putting them at risk for harm.  Unless cognitive dissonance is addressed, patients may not be open to deprescribing recommendations. Various techniques have been described for addressing cognitive dissonance during deprescribing conversations:  

• Direct: “I know you are taking a lot of medications, but I don’t think it’s good for you to be on this many. I want to reduce this to a more manageable number of medications for you.”
• Emotional: “I am worried about your falls. Some of your medications may be hurting not helping you by clouding your mind and affecting your concentration and balance.”
• Reading for Next Time: A randomized study of 303 long-term users of benzodiazepines (BZDs) showed that an interventional group who received a “Reading for Next Time” deprescribing brochure that described the risks of BZD use was significantly more likely to discontinue BZDs (number needed to treat, 4) than a control group (15). In its simplest form, “Reading for Next Time” is stating, “Here is some information regarding [medication X].  Read this prior to our next visit and we can discuss”.  Brochures are available for many medication classes via the Canadian Deprescribing Network (16). 

E – Empower patients and caregivers to continue the conversation:  Like advance care planning, deprescribing conversations should not be limited to one point in care.  Subsequent conversations are often needed to decrease unnecessary pill burden effectively. Clinicians can set up future conversations via motivational interviewing techniques towards the end of the visit. Sample phrasing include: “You bring up a good point about your fatigue. I would encourage you to ask your cardiologist what benefit metoprolol is providing you and what your time may look like if you were to discontinue it.” 

References

1. McNeil MJ, Kamal AH, Kutner JS we al. The burden of polypharmacy in patients near the end of life. J Pain Symptom Manage. 2016 Feb;51(2):178-83.e2. 
2. Scott IA, Hilmer SN, Reeve E et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015 May;175(5):827-34.
3. Anderson K, Stowasser D, Freeman C et al. Prescriber barriers and enablers to minimizing potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open. 2014; 4(12): e006544
4. Stevenson J, Abernethy AP, Miller C et al. Managing comorbidities in patients at the end of life. BMJ. 2004 Oct 16;329(7471):909-12.
5. Zhang YZ, Turner J, Martin P, et al. Does a consumer-targeted deprescribing intervention compromise patient-healthcare provider trust? Pharmacy. 2018 Apr; 16(2).
6. Collier KS, Kimbrel JM, Protus BM. Medication appropriateness at end of life: a new tool for balancing medicine and communication for optimal outcomes—the BUILD model. Home Healthc Nurse. 2013 Oct;31(9):518-24.
7. Qi K, Reeve E, Hilmer SN et al. Older peoples’ attitudes regarding polypharmacy, statin use and willingness to have statins deprescribed in Australia.Int J Clin Pharm. 2015 Oct;37(5):949-57.
8. Reeve E, Low LF, Shakib S, et al. Development and validation of the revised patients’ attitudes towards deprescribing (rPATD) questionnaire: versions for older adults and caregivers. Drugs Aging. 2016 Dec;33(12):913-928.
9. Case Western Reserve University. Center for evidence-based practices: Motivational Interviewing.  https://www.centerforebp.case.edu/practices/mi. Accessed 11/28/18.
10. Dunn A, Litrivis E. Aligning patient preferences and patient care at the end of life. J Gen Intern Med. 2011 Jul; 26(7): 681-682.
11. Heckman CJ, Egleston BL, Hofmann MT. Efficacy of motivational interviewing for smoking cessation: a systematic review and meta-analysis. Tob Control. 2010 Oct;19(5):410-6. 
12. Palacia A, Garay D, Langer B, et al. Motivational interviewing improves medication adherence: a systematic review and meta-analysis. J Gen Intern Med. 2016 Aug;31(8):929-40.
13. Pollak KI, Childers JW, Arnold RM. Applying motivational interviewing techniques to palliative care communication. J Palliat Med. 2011 May; 14(5):587-92.
14. Pollak KI, Jones J, Lum HD et al. Patient and caregiver opinions of motivational interviewing techniques in role-played palliative care conversations: A pilot study. J Pain Symptom Manage. 2015 Jul;50(1):91-8. 
15. 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 Jun;174(6):890-8.
16. Canadian Deprescribing Network.  www.deprescribingnetwork.ca. Accessed 11/7/18.

Conflicts of Interest: None

Authors’ Affiliations:  ¹Medstar Union Memorial Hospital, Baltimore MD; ²Université de Montréal, Montreal, Quebec; ³University of Maryland School of Pharmacy, Baltimore, MD; ⁴University of Pittsburgh Medical Center, Pittsburgh PAVersion History: originally edited by Sean Marks MD; first electronically published in December 2018.