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

Key Points

Question

Do physicians prioritize different ethical considerations when considering deprescribing medications for older adults (aged ≥65 years) with dementia?

Findings

In this national survey study of 890 primary care physicians, 9 factors influencing deprescribing decisions for older adults with dementia were prioritized. When a medication may increase risk of an adverse drug event or have limited benefit as a treatment, physicians are sensitive to concerns that deprescribing would worsen symptoms, are more reluctant to deprescribe a medication started by someone else, and less concerned about the cost of medication.

Meaning

Results of this survey study suggest that managing symptoms and well-being and working with other clinicians are priorities for clinicians managing medications for older adults with dementia.

Abstract

Importance

Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population.

Objective

To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions.

Design, Setting, and Participants

A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021.

Main Outcomes and Measures

The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing.

Results

A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice).

Conclusions and Relevance

Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.

Abstract

This survey study of primary care physicians assesses the prioritization of different ethical considerations when considering deprescribing medications for older adults with dementia.