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Question: How would you code a gradual dose reduction (GDR) if the physician agreed, but then the family refused to allow the medication to be reduced?
Answer: For the basic question, if the GDR did not take place, then it could not be coded as a dose reduction. I would suggest that you make a note in the medical record of the discussion with the family.
Overall this is a very important issue. It sounds like a discussion with the family, DON, physician, medical director and possibly the pharmacist might be needed. I am assuming the resident has no cognitive abilities to make a decision? Is that verified on the MDS? What reasons is the family giving? They might have experience with the resident of which the physician is not aware. Has something happened to the resident before when the drug was reduced or discontinued? Has it been documented that the risks and benefits have been reviewed with the family? Does the resident/representative realize that the drug is being used for an off-label condition (if that is true)?
Also, you need to consider if the resident has been adjudged incompetent and if not did the resident designate a representative? Does the drug meet the definition of a chemical restraint? What symptoms is the resident exhibiting to warrant the use of the medication? Is that behavior documented consistently in the medical record?
Does the family understand what the staff will do while the drug is tapered (ex. monitoring, increased activities, visits from social services)? What non-pharmacological interventions have been implemented and care planned for the behaviors exhibited by the resident? Are they effective? Are they consistently implemented?
I am not trying to make this question more difficult than it is, but there is so much for the team to think about when trying to reduce medications. Medication management is getting so much attention - whatever the outcome, I would recommend having the conversations and the decisions well-documented.
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