In the March 27, 2006, issue of the Archives of Internal Medicine, four University of Chicago physicians propose the first general framework for withholding or discontinuing medications, adding life expectancy, goals of care, treatment targets and time until benefit to the usual equation of drug plusses and minuses.
"Our framework was designed to help patients and physicians decide when to stop taking even safe and effective drugs in situations that are often radically different from those where the medications were started," said geriatrician Holly Holmes, M.D., instructor of medicine at the University of Chicago and lead author of the study.
"We wanted to provide a road map," she said, "that would steer people away from the prescribing cascade that is common for patients late in life and guide them past the barriers that prevent removal of treatments that may no longer be effective."
The impetus for the guidelines came from some misguided advice. The authors care for patients at a nursing home. The pharmacy that supplies the nursing home monitors physician-prescribing practices and offers suggestions. After one review, the pharmacy sent a fax pointing out that, according to accepted guidelines, two patients at the nursing home ought to be taking a statin -- a cholesterol-lowering drug that can, over time, reduce the risk of heart attack.
"One of those patients was more than 100 years old, quite frail, with advanced cancer and multiple other medical problems," Holmes said. "The other one was dead. It made us wonder whether something wasn't missing from those guidelines."
There are well-tested algorithms for prescribing drugs and avoiding inappropriate medications
Contact: John Easton or Catherine Gianaro
University of Chicago Medical Center