Good communication is essential when changing medications. Resistance from residents and prescribers is common and needs to be addressed carefully to achieve both short- and longer-term goals.
Sample letters for prescribers and sample letters for residents and family or care partners are provided under the “Additional Resources” section and may be adapted to fit local circumstances. Such letters can be an important part of good communication but should be supplemented with other individual communication as needed.
| Improving Communication Around Medication Changes |
|---|
| Explain changes and why they are being made |
| Understand and respond to concerns. Use reflection techniques to paraphrase what the person has said to you, to show you are listening and not just trying to make them hear you. |
| Be attentive to emotion. This may include fear of changes, perception of abandonment, worries about rationing of care, and perceived threats to authority or autonomy Engage peer supporters |
| Partner with resident/family/caregiver and prescriber around changes; listen |
| In general, defer making changes if resident or prescriber opposed, unless urgent health considerations require immediate action |
It is important to explain to residents and their families and care partners the reason for any changes that are suggested, and to understand and address their concerns. Suggestions for medication discontinuation or changes in dose timing can induce cognitive conflict. For example, a resident might say or think “My doctor told me for years that I needed to take this medicine - and now you are telling me I should not take it?” Or, a family member might wonder “My mother’s doctor always told her she needed to take her statin at bedtime - and now they are telling her to take it in the morning. They don’t know what they’re doing!”
Explaining why things are different now can be helpful. For example, one might explain “I know you have been taking this medication a long time. But, your situation has changed and we now know that it’s not helpful to you.” Or, one might explain a timing change by saying “For a long time we thought that taking statins at bedtime was best. But we now know that they have pretty much the same effect when taken at other times of day.” One can also reassure residents that if they feel worse after stopping a medication, the medication can be restarted. Discussion of COVID-19 and how medication-related activities may affect their health and staff health may be useful.
Medication changes can induce strong emotions. People can feel that stopping medications means that their health care team doesn’t care about them, is abandoning them, or is rationing their care to save money. Such concerns can be especially prominent among people who don’t trust their health care team. People can also fear the unknown: “If I stop or change this medicine, maybe something bad will happen to me.” Understanding and addressing these emotional responses is critical. If resistance to medication changes is suspected, it can be useful to ask about and elicit concerns. Peer encouragement and involvement of resident leaders or other peer advocates may also be helpful.
If residents or their families or care partners are skeptical or distrustful of change, it is typically better to wait until their concerns can be resolved before making changes, unless urgent health considerations dictate otherwise. As PALTC clinicians and leaders know well, building and maintaining trust and a positive relationship is important for good health and effective partnership in future health decisions.
Similar principles apply to prescribers, including the importance of trust and fear of potential harms that may occur after stopping or changing a medication. Prescribers may also feel protective about residents under their care and resent perceived challenges to their judgment or authority. Expressing appreciation and seeking their partnership in medication changes may be helpful to achieve their concurrence with desired changes. This partnership goes both ways; prescribers may identify issues unknown to staff that change the calculation about whether a medication change is advisable.
While these relationships are important, they do not supersede responsibility to the resident: if there are immediate dangers to resident health and safety it is appropriate to intervene first and resolve potential relational conflict later.