Discussion
dementia
We conducted a national survey study exploring how primary care physicians prioritize barriers linked to several ethical and pragmatic considerations when making deprescribing decisions in caring for older individuals living with moderate dementia. To our knowledge, this is the first exploration of how ethical considerations affect physician deprescribing. We found that when a medication is known to have an increased risk of an ADE or has limited to no benefit as a treatment, physicians are particularly sensitive to patient or family member concerns about deprescribing (that is, autonomy). Physicians also appear to be reluctant to interfere with their colleagues’ medical management and deprescribe a medication started by someone else (autonomy and nonmaleficence) and are much less concerned about the financial impact of continuing or discontinuing a medication (justice). Overall, barriers related to the ethical principle of justice appeared to be less important barriers than those related to beneficence, nonmaleficence, and autonomy.In both clinical scenarios, our findings that physicians view symptom management as the most important barrier to deprescribing aligns with a previous national physician survey of cardiologists, general internists, and geriatricians trying to deprescribe cardiovascular medications in older adults.Our finding that physicians view medications being prescribed by other specialists/colleagues as a major barrier to deprescribing bolsters similar findings in other recent physician and primary care clinician surveys on deprescribing cardiovascular medicationsOur finding that physicians consider the financial impact of continuing or discontinuing a medicine as the least important barrier to deprescribing may provide an alternative entry point to starting conversations about deprescribing with their patients and may require clinician education. As highlighted by Hung et al,Overall, our findings have implications for physicians and future research. By linking barriers to ethical principles, physicians will be able to reflect on what might be behind the barriers they experience and explore whether they are allowing a single principle, such as autonomy, to dominate their decision-making. This work may inform research aimed at developing guidance on how ethical principles can be used as a framework to support decision-making around deprescribing, especially when there is a lack of evidence to inform the likely benefits and harms of deprescribing certain medications in complex situations. Given the finding that factors related to nonmaleficence do appear to play a large role in deprescribing decision-making, future research could explore how this could be used as a trigger for deprescribing. In qualitative studies,Our work may also inform future designs of deimplementation interventions to deprescribe inappropriate medications. For example, a common physician-level characteristic that affects deimplementation is past negative experiences.