Ambiguities in Discontinuing Medication: How General Practitioners Make Sense of Discontinuation and Their Strategies for Reducing Ambiguity

This paper will examine how general practitioners (GPs) deal with ambiguity in order to perform medication discontinuation. I examine the case of statins as is it a strongly recommended drug for reducing the risk of cardiovascular disease, however there several possible complications with taking the drug such as side effects, drug-drug interactions and lack of effect because of old age. Discontinuing the drug is therefore not a straightforward task, rather it involves a great deal of ambiguity. Drawing on interviews and observations of Danish GPs and document analysis of two independent drug recommendation bodies in Denmark, I analyzed GPs’ strategies for dealing with three important problems related to discontinuation: 1) assessing the validity of patient reported side effects as a reason to discontinue; 2) discontinuing a hospital specialist’s prescription; 3) assessing the likelihood of a positive outcome after discontinuation. Drawing on sensemaking-theory, I outline the strategies a GP may use for dealing with ambiguity and selecting alternatives with regards to patients drug prescription. I show how these strategies are shaped by professional qualities, including: terrain of responsibility (whose responsibility is it to discontinue), prioritizing ability (how comfortable is the GP prioritizing from a long list of medications), shared communication with patients (how two way is the communication) and discontinuation confidence (are GPs willing to trial discontinuation without the promise of a positive outcome). I conclude with recommendations for how to support appropriate discontinuation in primary care settings, including updating guidelines to explicitly acknowledge multimorbidity in patients and the importance of medication prioritizing, creating discontinuation alliances for GPs, e.g. with clinical pharmacists and gerontologists, and developing positive metaphors for ‘discontinuing medication’ to enable better communication with patients, e.g. drug holiday or medication pruning.