The knowledge work of prescribing

Hopefully through our discussion about polypharmacy, it has become clear that knowledge work is an integral part of tailored de-prescribing.

Figure 1: 4 Elements of Knowledge Work

We use knowledge work to innovate and understand a patient’s priorities regarding their medication, then integrate a patient’s priorities with what the guidelines and our professional wisdom tell us is safe and in the patient’s best interests.

When consulting people like Brian, we use knowledge work to facilitate shared-decision making. We apply our knowledge to support patients to achieve their best health for daily living and should consider whether medicalisation, including prescribing medication, will help or hinder our goal. After scanning Brian’s list of medications and past medical history, I suspect you identified interactions between several of his tablets which could have caused or exacerbated health problems.

Brian wanted to escalate his opiate treatment, but chronic pain management guidelines advise against this. If Brian became sedated he would be at increased risk of falls, whilst his constipation would probably also get worse. There are many other potential long-term implications of opiate use to consider.

We all know from experience that conversations about opiate de-escalation are inherently difficult. Taking a pill may be preferable to other solutions, which can require someone to take a more active role in their care, or accept that their chronic pain can’t be cured, only managed.

Consequently, building trust to foster any shared decisions is vital, so any uncertainty can be managed through a trial and learn approach, with incremental changes made to minimise harm. Generating an individualised interpretation of his symptoms will help to support tailored care, whilst follow-up will facilitate an evaluation of his response and a review of his tailored management plan if necessary.

Organisational support to facilitate continuity of care is fundamental, whilst multidisciplinary team work within our organisations can help us to share the burden of complex decision making and learn from each other. Having the same ethos within a practice regarding certain decisions, for instance, opiate de-prescribing, can help to foster trust between healthcare professionals and patients and ensure the same message is communicated to patients across a practice and beyond.

In the next step, we’ll be encouraging you to reflect on this learning and how you might apply it in your future practice.