Choosing Wisely Canada recommendations

Psychiatry recommendation 12
Canadian Geriatric Society recommendation 4

Do not use antipsychotics as the first choice to treat behavioural and psychological symptoms of dementia.

How have you implemented these recommendations in your practice?

To cut prescriptions for antipsychotics, my team and I made a plan. First, we asked the Behavioural Supports Ontario nurses at each long-term care home to try nonpharmacologic interventions (eg, redirecting exit-seeking patients, calming patients with activities, music, and hobbies). We ensured that behaviour such as calling out and verbal and physical aggression were not due to medical reasons such as constipation, pneumonia, urinary tract infections, or osteoarthritis pain. Then we reviewed the charts of all patients taking antipsychotics and chose those patients we believed could succeed without them. Over 4 weeks, we weaned many patients off antipsychotics.

With some patients we tried analgesics, even if no pain was evident. This helped those who were unable to tell us how they were feeling.

Our current weekly process is as follows: the pharmacist lists the drug the patient uses; the nurse (who knows the patients personally) states whether he or she thinks a slow taper could work; we collectively make a decision; and then we start implementing the required behavioural modifications.

In long-term care, there is pressure to sedate for sure; not medicating patients who can be harmful to themselves and others is dangerous. We implemented this Choosing Wisely recommendation by practising behavioural modification and giving patients meaningful tasks. Today only 20% of our patient population uses antipsychotics.

How have you brought the Choosing Wisely principles to your relationship with patients?

Time management is key. As physicians, we are tempted to do the quickest, easiest things when we feel rushed—like write a prescription or order a test. It takes longer to explain why something is not necessary and to discuss risks and benefits. Physicians overprescribe and choose unwisely because of the pressure to keep their patients happy.

I make rounds 3 days a week at 9 am (not during meals). With this schedule, I save time because I can diagnose diseases early, when they are easier to treat. I delegate my meetings and ensure that families’ questions are medically relevant. I review patients’ medications, ensuring they are appropriate for their conditions, working with the families and making decisions with them. I do not fight the battles that I will not win.

By the third day of rounds, patients’ immediate medical needs have been met, families have been involved, and nurses’ needs are addressed.

What does Choosing Wisely mean to you as a family physician?

Choosing Wisely is about necessary health care, but it is also about conversations. Over the years I have learned how to communicate through trial and error. I try to impart my knowledge to younger doctors by bringing them into family meetings and showing them how to talk to families. Each family is different, and the conversations need to reflect that. I tell families that Choosing Wisely is expert driven and that it is what I do for myself as well.

To me, Choosing Wisely is a reflection of the way medicine is changing. I always ordered an electrocardiogram for patients’ annual physical examinations, as I was taught at school; however, Choosing Wisely’s evidence-based recommendations made me realize it was time to rethink things. The way something has always been done does not mean it is the correct thing to do. We all need to be open to changes in practice.