Actions include:

• obtain medical, social and drug history from available health records and functional history from patient and/or carer
• conduct medication reconciliation to establish what they are taking and how
• ask how medicines fit in with or impact on their overall health goals with respect to patient’s functionality, life expectancy and frailty
• assess whether they have shortened life expectancy
• assess if they are frail
• discuss what medicines matter to the patient and/or carer, any problems they have, their experience of taking medicines and how it fits into their typical day

Agree the medicine-related issues/benefits the patient wants to be addressed for this visit, based on your patient assessment.

Using agreed list with patient/carer, consider ALL the medicines according to the best available research evidence and in relation to the patient perspective.

Use an evidence-based tool e.g. NHS Scotland resource, NICE multimorbidity guidance, STOPP/START.

Initial discussion

Discuss with patient to identify:

• potential and actual benefit
• harm
• medicine and non-medicine alternatives for each drug reviewed

The objective is to ensure that EACH medicine reviewed is tailored to the patient’s circumstances, clinical and social situation and co-morbidities.

Consider the patient’s perspective

Consider patient preferences and ability to adhere to the agreed regimen:

• use deprescribing tools e.g. CaDeN, GPGP algorithm, NO TEARS
• identify any new symptoms/conditions, review in relation to when the medication was started and address
• ask about conditions which are active/inactive, time bound or resolved.
• establish if there a valid indication for each drug
• explore what perceived/actual harms or benefits are they experiencing for each drug in relation to their condition:
  • Start with general, open questions e.g. “Tell me about your pain medicines”
  • Move towards more specific, closed questions e.g. “Do you think the medicine is working?”
• explore specific risks and benefits for each drug for your individual patient circumstances including shortened life expectancy; note any essential drugs?

Actions should include:

• agree a way forward with the patient, including explaining referral to prescriber where appropriate and check patient understanding of next steps.
• present options to prescriber in simple format, if not prescribing,
• provide a written summary to the prescriber and/or in the patient’s record, highlighting rationale, agreed action and monitoring, with a copy to the patient, where appropriate.

Produce a written summary highlighting:

• rationale
• agreed action for each drug change and monitoring
• provide this information to the community pharmacist, social care, allied health professionals, care home staff and hospital clinicians as needed
• follow local guidelines around consent/governance

Document review so information can be accessed by relevant people, following local processes.

Actions should include:

• discuss the monitoring patient can expect, by whom and when
• inform others who need to know about the changes made and/or act on them (with the patient’s consent as appropriate)
• ensure changes are clear, together with agreed actions and next steps, especially if no prescription will follow