Synopsis
Reconcile every medicine against current goals, prognosis, time to benefit, immediate harm, withdrawal risk and route, then stop, taper, continue or replace treatment through shared decisions and active follow-up.
- Deprescribing is a planned clinical intervention, not simply deleting prescriptions: identify indication, current benefit, time to benefit, burden, interaction, route and withdrawal risk for every medicine.
- First-line reconciliation includes prescription chart, repeats, specialist medicines, injections, patches, inhalers, over-the-counter products and what the person actually takes.
- Prioritise medicines causing immediate harm or burden, those without a current indication and preventive treatment whose benefit lies beyond the person's likely timeframe.
- Continue medicines that relieve symptoms or prevent a near-term crisis, changing route when swallowing fails; type 1 diabetes always needs basal insulin and corticosteroid dependence needs cover.
- Never abruptly stop a medicine with dangerous withdrawal or rebound potential, including systemic corticosteroids, benzodiazepines, antiseizure medicines, clonidine, some beta blockers and long-term opioids.
- Anticoagulant, antiplatelet, insulin, antihypertensive and antimicrobial decisions are individual balances, not automatic rules triggered by a palliative label.
- Explain that stopping long-term prevention can reduce tablet burden, falls, bleeding, hypoglycaemia and monitoring while preserving active symptom care.
- Assess decision-specific capacity, respect a valid advance refusal and use a documented best-interests process when capacity is absent, involving those important to the person without transferring the decision to them.
- For each change record stop versus taper, reason, expected effect, possible withdrawal or recurrence, monitoring, review date and who to contact.
- The gold-standard review is repeated after transitions and clinical change, because prognosis, renal function, swallowing and priorities evolve.
Key red flags
Systemic corticosteroid used for weeks or at suppressive doses must not be stopped abruptly without adrenal-risk assessment.
Type 1 diabetes requires ongoing basal insulin even when oral intake stops.
Abrupt benzodiazepine or antiseizure withdrawal can cause agitation, delirium and seizure.
Falling kidney function can convert a previously tolerated opioid, gabapentinoid or anticoagulant dose into toxicity.
Recurrent hypoglycaemia with poor intake requires same-day simplification of insulin or sulfonylurea treatment.
A recent stent, acute thrombosis or unstable cardiac syndrome may make abrupt antithrombotic withdrawal immediately hazardous.
A medicine stopped in one setting can be automatically restarted from an unreconciled repeat list unless every prescriber is informed.
New seizure, severe hypotension, vomiting, hypoglycaemia, hyperglycaemia or autonomic distress after cessation requires immediate medicine and metabolic review.
Investigation priorities
Compare all clinical records with containers and patient or carer report, including non-oral, specialist and non-prescribed products.
Management branches
Prognosis, function, kidney or liver status, goals or swallowing changes, or a care transition occurs.
- Reconcile the actual regimen and ask the person what helps, harms and creates burden; involve a pharmacist for complex interactions and formulations.
- Map indication, time to benefit, immediate harm, withdrawal risk and feasible route and identify duplicates and prescribing cascades.
- Rank urgent harm reduction, safe route conversion and lower-priority preventive stopping and agree the sequence with the person or lawful process.