Lessons learned from Canadian family physicians deprescribing medications in older adults – a five-year retrospective review of medico-legal cases

Medication-related safety incidents are more common in older adults than in younger populations. Medication review and optimization, including deprescribing, are essential components of strategies to reduce medication-related harm. Deprescribing aims to minimize therapeutic burden by reducing medications that no longer provide net clinical benefit or by substituting safer alternatives. Herein we sought to use a national pan-Canadian repository of medico-legal cases to identify opportunities for improving deprescribing practices in primary care for older adults. We conducted a five-year retrospective review (2018–2022) of closed Canadian medico-legal cases relating to deprescribing involving family medicine physicians and patients age 65 or older. We analysed cases related to deprescribing and created composite case examples to illustrate both areas for improvement and examples of appropriate care despite the receipt of a complaint or civil legal action (collectively, medico-legal cases). We identified 31 medico-legal cases, of which 29 had undergone expert review. Experts identified areas of improvement related to deprescribing including conducting assessments to determine appropriateness of deprescribing, using a multidisciplinary approach to create a safe tapering plan that includes monitoring and follow-up, establishing clear communication with patients and their authorized substitute decision-makers, and documenting clearly and appropriately. Although experts often explicitly identified these elements as present, they were critical of the deprescribing-related care in half of cases. Medico-legal cases highlight several key areas for improving deprescribing in primary care, particularly around comprehensive patient assessment to inform deprescribing decision-making and clear communication of treatment plans with relevant decision-makers. The cases also demonstrate that the process of deprescribing and the patient-physician relationship is complex and that complaints can occur even when physicians are safely deprescribing.