A new column of mine has been posted on NPR’s website about “de-prescribing,” the art of pruning medications from older adults that take too many of them, a condition we refer to as polypharmacy.
It’s well-known that being on too many medications can lead to more side effects and drug-drug interactions, so anything medical professionals can do to minimize such negative outcomes is welcome. Thus we revert to our Hippocratic doctrine: First, do no harm.
Contrast that with the competing ethical imperative toward beneficence — to do good for patients. Medical science teaches us that many (though far from all) of the medications we prescribe for chronic illnesses (e.g. cardiovascular conditions) lead to fewer ‘events’ (think heart attacks & strokes), which prolong lives.
As a result, doctors wind up prescribing a lot of stuff — and decades of medical practice and now guidelines and quality metrics push us to do this even further.
One area I’d like to see science help us is in identifying “The Inflection Point of Aging,” which I define as the point in a person’s life when we can pare down ‘aggressive’ treatment of chronic conditions because it becomes counterproductive: when taking the “medically proper” action is likely to cause more harm than good.
This whole notion arises out of recent discourse: As I recently blogged, the SPRINT Trial, which was stopped early because it showed that treating blood pressure even more aggressively than we’d previously thought leads to fewer bad ‘events.’ How low, I wonder, is too low?
Also, an article in the Atlantic by medical pundit Ezekiel Emanuel titled “Why I Hope to Die at 75” emphasized this idea.
Emanuel is a known iconoclast, but I appreciate his efforts to stir up dialogue and get us talking about important issues that we are otherwise reluctant to discuss. In this case, I think his editors at the Atlantic did him a disservice, because the provocative headline of the article caused a furor and detracted from his real message, which was simply this: There comes a point where undergoing standard medical practices no longer makes sense. That point is different for everybody and is dependent on a person’s values as much as their physiology. Emanuel never said he wants to die at 75, merely that he plans to stop seeking medical interventions at that age — two very different ideas.
If you click over to the NPR column, you can see that anecdotally, we care for patients for whom physiology does change — and it therefore doesn’t make sense to keep doing the same things over and over. It’s trite to say it (and you’d be amazed at how challenging it can be to fight medical inertia), but we must think about each patient individually and truly weigh the risks and benefits of adhering to population-based norms and recommendations when goals and bodies change.