Pilot study of MEdication RAtionalization intervention

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A large majority of Canadians die during or soon after an admission to an acute hospital, where the focus is often on reversing acute conditions rather than providing comfort care for patients with a short prognosis. This focus leads to the use or continuation of therapies that offer little benefit to patients with a limited prognosis, while comfort medications are frequently neglected. Prescribing or continuing non-beneficial medications in seriously ill and frail elderly patients is potentially harmful, costly, and time-consuming; and failing to offer comfort medications to symptomatic patients nearing the end of their life is tantamount to neglect. Rationalizing medications (i.e. stopping non-beneficial medications and offering comfort medications) could be another means of improving quality while reducing costs for the seriously ill and frail elderly. Many hospitals already employ pharmacy-focused quality improvement projects such as medication reconciliation and antibiotic stewardship, which have led to significant improvements in patient safety and reductions in cost.

We propose to conduct a pilot study of an innovative MEdication RAtionalization (MERA) team on the General Medical Inpatient ward. The MERA team would include members of multiple disciplines (medicine, pharmacy, nursing) that would meet regularly with admitting physicians to review the medications prescribed for any patient meeting specific age and illness criteria. The team would review the rationale for each medication, recommend discontinuing any non-comfort medication that has no clear short-term benefit to the patient (e.g. statins), and suggest adding orders for comfort medications (e.g. opioids, sedatives) as needed. The summary recommendations will be proposed to the patient or substitute decision-maker, and changes will be made only with their consent.

Dr. James Downar, MDCM, MHSc, FRCPC is a Critical Care and Palliative Care Physician at the University Health Network and Sinai Health System in Toronto, and an Associate Professor in the Department of Medicine at the University of Toronto. He graduated from McGill Medical School and completed residency training in Internal Medicine, Critical Care and Palliative Care at the University of Toronto. He has a Master’s degree in Bioethics from the Joint Centre for Bioethics at the University of Toronto. He is the Program Director for the Subspecialty Residency Program in Palliative Care at the University of Toronto, the chair of the Postgraduate Education Committee of the Canadian Society of Palliative Care Physicians and the chair of the Ethical Affairs committee of the Canadian Critical Care Society. He is an Associated Medical Services Phoenix Fellow for 2016-17. His research interests include communication and decision-making for seriously ill patients and their families, palliative care for the critically ill and palliative care for noncancer illnesses.