Examining Medical Interventions in Older Adults with Limited Life Expectancy-Opportunities and Challenges for De-implementation.

Purpose: The benefits and harms of medical interventions shift as patients age, calling for re-evaluation of each intervention's appropriateness and alignment with patients' preferences. Continued use of medical interventions when harms outweigh benefits is common in older adults with limited life expectancy. This critical review aims to describe the opportunities and challenges of de-implementation in older adults with limited life expectancy, focusing on the role of patient preference and shared decision making. Findings: We describe three examples where de-implementation may be considered in older adults with limited life expectancy-cancer screening, polypharmacy, end-of-life care-and the associated de-implementation challenges. The challenges stem from the need to change established behavior and shift from age-based to life expectancy-based decision making. Existing de-implementation frameworks do not incorporate patient preferences whereas shared decision-making frameworks do not consider the challenges specific to de-implementation. Conclusions: Significant research gaps exist at the intersection of de-implementation, shared decision making, and aging research. Considerations for de-implementation would benefit from evaluating the preference sensitivity of the decision. This should be informed by the strength of evidence, the extent that the potential harms outweigh the benefits, and whether the intervention is life-sustaining where de-implementation would be irreversible.