To optimally solve critical deficits in the medication-use process for most Americans, especially the vulnerable elderly, efforts to improve medication discontinuation must be coupled to efforts to improve medication initiation. Improving medication discontinuation is complex but feasible and indeed necessary to promote the health and safety of the public. Multilevel approaches to improve both the initiation and discontinuation of medications are consistent with the Institute of Medicine’s mission to design a safer health care system.4
For one, our present health care system provides little incentive for patients or providers to stop therapy. Consistent with patient-centered care, it is essential that the patient and, where relevant, the patient’s caregiver are fully informed of and participate in the discontinuation process, including follow-up with providers. Further, patients should be taught and encouraged to inform all of their providers about medications that have been recently discontinued or initiated, especially self-initiated medications, supplements, or other therapies. Prescribers are in a key position to recognize an indication for discontinuing a medication, identify and prioritize medications to be targeted for discontinuation, and discontinue the medication with appropriate subsequent monitoring. Prescribers need to realize that it is sometimes appropriate and necessary to stop a medication that another prescriber initiated. More importantly, prescribers should communicate this information in a way that facilitates the process. Efforts to teach prescribers the skills of shared decision making are sorely needed.
Pharmacists are important resources for prescribers and patients. Pharmacists provide information both to prescribers on a medication’s properties and how to taper or discontinue a medication and to patients about medication discontinuation, such as information about ADRs and ADWEs. Further, pharmacists are often the most accessible of health care providers and, therefore, they are in key positions to monitor patients. Strategies to improve pharmacists’ involvement in the medication discontinuation process should be explored. Nurses bring to the discontinuation process their particular expertise in working with individual patients and patient’s families to facilitate learning, adjustment, and behavior change. Other health care professionals, such as advanced practitioners, also contribute their special expertise in managing and monitoring patients during the discontinuation process. Similarly, strategies to improve nurses’ and other health care professionals’ involvement in the medication discontinuation process should be investigated.
The documentation of information on medications between care settings is particularly poor.34
Better documentation in patients’ medical records, especially at key points during transitions in care, will undoubtedly improve medication discontinuation by reducing unnecessary continuation of potentially harmful medications and preventing medications from getting inadvertently discontinued or restarted after discontinuation. As evidenced by the case example, documenting all of the medications’ indications will improve continuity of care by helping to identify medications that could potentially be discontinued.
Finally, although most efforts to change behavior and practice need to be directed at the patient and clinician to have the greatest effect, to be successful, systems that improve all stages of the medication-use process and provide more effective protection against errors need to be developed. Technology such as computerized physician order entry has been advocated as one of the most effective means of improving the prescribing stage, particularly medication initiation. Technology may also be used to improve medication discontinuation. Clinical decision support systems, for example, can recognize medication indications and identify high-risk or unnecessary medications that should be targeted for discontinuation. When used in concert with the health care team, these support systems can also facilitate patient care planning and assist with monitoring.35
Technological systems deserve additional research to elucidate their value in potentially improving the medication discontinuation process.
While we have purposely not included all the features that would be expected to improve medication discontinuation, such as determining which and when medications should be targeted for discontinuation, these are equally urgent considerations. Also, an important question is whether a systematic approach to discontinuing medications improves patient outcomes. Before the relationship between the discontinuation process and outcomes can be examined, it is necessary to have a workable approach to discontinuing medications and to have at least a preliminary understanding of the process for doing so. Such a process as we propose should, therefore, be regarded as a necessary first step in programmatic outcomes-based research of discontinuing medications.
In summary, the prescribing stage of the medication-use process must incorporate the related challenges of discontinuing medications as well as prescribing them. Reevaluating the prescribing stage in these terms is important to improve the quality of patient care and reduce the costs attributable to medications. Medication discontinuation warrants further attention to understand best practices and the effect on health outcomes. A formalized approach for rationally discontinuing medications is a necessary antecedent to building a safer health care system.