Hello deprescribers! Today we have an interview with Ana Amaral, a nurse and researcher from Portugal. We asked her about her experience as a nurse working in long-term care and palliative care and about her Master’s work related to the role of nurses in deprescribing in this setting. Here we go!
Q: You recently submitted your thesis about deprescribing in long-term care and palliative care. Congratulations! First off, can you tell us a little bit about your reasons for focusing on this (important!) topic in your thesis?
Ana: In most long-term care and palliative care facilities, we as nurses have a central position in relation to patients’ medication use. However, when I worked as a nurse around these patients, I found that there were many routines around medication preparation and administration but almost no routines for questioning the appropriateness of the patients’ medication list. Wanting to help patients, we often try to find possible causes of an acute disease when a patient’s health status changes rather than considering possible drug-related causes. And then when patients are complaining about some new symptom they have, our mind flies first to a pharmacological solution to discuss with the physician. But we do not think about the consequences that might have on medication burden. So to me deprescribing seems like a concept that should be incorporated – questioning the medication regimen or looking for medications there are no longer adequate in meeting goals of care and that might be having a negative impact in quality of life.
Deprescribing is often described as a multidisciplinary team effort. However, I found that there was limited research on how we, as nurses, can promote deprescribing when appropriate. That is why I decided to conduct a scoping review about this topic, aiming to describe the role of the nurse as a member of the multidisciplinary team in long-term care and palliative care.
Q: What did you find in your thesis?
Ana: In my thesis I looked for possible nursing interventions and for tools to be used by nurses to promote deprescribing. Interventions were mapped in nine domains: educational training, patient assessment, health education, medication review, therapeutic relationship, leadership/coordination, care management, research, and awareness.
I found that nurses can play a major role in deprescribing in long-term care and palliative care, as members of the multidisciplinary team, in part due to the close relationship we have with residents and the amount of time that we spend with them. Through patient assessment nurses, can gather a lot of valuable information that can lead us identify possible reasons for deprescribing. These are things like goals of care, negative drug-related reactions, medication burden, reasons for non-adherence to medication regimens, potential inappropriate drugs regarding to patients’ condition, and problems related to administration. And then nursing assessments for things like falls risk, quality of life, behaviour, function, and cognitive impairment can support deprescribing and evaluate outcomes of deprescribing. When medications are discontinued, we need to be aware of that and monitor reactions like symptom recurrence and/or withdrawal reactions. We should also be promoting non-pharmacologic interventions, or as needed medication use when possible. I would say that beginning to the end, we can ensure that deprescribing goes as planned, ensuring the continuity of care.
Through educating and training, nurses with knowledge in the field can empower and support their peers about the concept of deprescribing and our role in this process. Methods like “train the trainer” and mentoring are often mentioned in the literature. As an example, we can teach our peers about the appropriate management of behavioral and psychologic symptoms of dementia, focusing on non-pharmacologic interventions. Additionally, we can also try to incorporate deprescribing in nursing curricula. Nurses can also educate patients and caregivers to facilitate deprescribing, which we also found examples of in the literature.
In our scoping review, we found that nurses can use tools to assess people’s medications. The most commonly mentioned tools to help nurses evaluate patients’ medication regimen were “START and STOPP”, “Medication Appropriateness Index”, “Medication Outcome Monitor”, “Neuropsychiatric Inventory Nursing Home Version” and quality of life scales. Tools like “the Patients’ Attitudes Towards Deprescribing (PATD) questionnaire” and the deprescribing.org guidelines were specific to deprescribing.
Q: Do you plan to follow up on the findings in your thesis? What do you consider the main implications of your findings with respect to clinical practice in long-term care?
Ana: If we have a role, we have a responsibility in this process, so first I am looking forward to sharing my findings with the scientific community, and particularly with my nursing colleges and other health care practitioners. I hope that this review is a starting point for implementation of deprescribing in nursing practice, with a more sustained approach. I believe that by incorporating deprescription into our practice we will promote a change in the culture of care because it will promote critical analysis of drug therapy and raise awareness. I believe that we need to have the whole team focused on the same target to achieve the results that are needed.
Q: From your point of view as a nurse and researcher, what are some of the key areas of focus for deprescribing in patients in long-term care and palliative care?
Ana: In these settings, we work in a high proximity with a relatively small multidisciplinary team, so I believe that we should focus on developing projects that define and reflect the role of the different members of the health care team. It will be particularly important to know how we can perform the best by using all the team efforts.
Other areas that I find important to explore is the impact deprescribing could have on patient care if it became part of the nursing education curricula in these settings.
Q: Last but not least: What is your most satisfying deprescribing target?
Ana: Honestly, I find all targets very important. However, having to pick one I would choose the antipsychotics used to control the psychologic and behavioral symptoms associated with dementia. I feel that we do not reflect enough about the dementia developmental course because we somehow treat this condition as static when it is not. Additionally, sometimes, by offering a non-pharmacologic solution or by eliminate some “triggers” we can help solving the problem.
To finish the interview, I would like to share my gratitude towards my professors who made this journey possible for me, Prof. Marília Dourado and Prof. Manuel Lúis Capelas, teachers of the Master’s degree program in long-term care and palliative care at the University of Coimbra – Faculty of Medicine. A special thank you for Prof. Isabel Vitória Figueiredo who let me attend some of her classes of the Master’s degree program in Applied Pharmacology at the University of Coimbra – Faculty of Pharmacy.