Fifteen Things Physicians and Patients Should Question in Post-Acute and Long-Term Care: 

1. Don’t insert percutaneous feeding tubes in individuals with advanced dementia. Instead, offer oral assisted feedings.
2. Don’t use sliding scale insulin (SSI) for long-term diabetes management for individuals residing in the nursing home.
3. Don’t obtain urine tests until clinical criteria are met.
4. Don’t prescribe antipsychotic medications for behavioral and psychological symptoms of dementia (BPSD) in individuals with dementia unless management of potential underlying causes fails to respond to best treatment practices. Only use for symptoms that severely impact quality of life or safety from self and/or others, in lowest dose possible and with frequent re-assessment for necessity and efficacy.
5. Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.
6. Don’t place an indwelling urinary catheter to manage urinary incontinence.
7. Don’t recommend screening for breast, colorectal or prostate cancer if life expectancy is estimated to be less than 10 years.
8. Don’t obtain a C. difficile toxin test to confirm “cure” if symptoms have resolved.
9. Don’t recommend aggressive or hospital-level care for frail individuals without a clear understanding of the individual’s goals of care and the possible benefits and burdens.
10. Don’t initiate aggressive antihypertensive treatment in frail individuals ≥60 years of age. For frail individuals with hypertension, multiple medical comorbidities, and limited life expectancy, use clinical judgment, incorporate patient/family preferences, and evaluate risk/benefit in deciding on medication(s) and the intensity of control.
11. Don’t continue hospital-prescribed stress ulcer prophylaxis with ProtonPump Inhibitor (PPI) therapy in the absence of an appropriate diagnosis in the post-acute and long-term care (PALTC) population.
12. Don’t order routine follow up chest imaging for post-acute and long-term care residents with community acquired pneumonia whose symptoms have resolved within 5–7 days.
13. Don’t routinely prescribe or continue sedative hypnotics such as Restoril or Ambien, diphenhydramine (Benadryl), benzodiazepines, or Serotonin Modulators (Trazadone) for long-term treatment of sleep disorders in geriatric populations. Consider the use of nonpharmacological interventions (e.g., physical activity, a regular schedule or cognitive behavioral therapy.) 
14. Don’t routinely prescribe or continue acetyl cholinesterase inhibitors or N-Methyl-D-Aspartate antagonists in patients with advanced dementia.
15. Don’t provide long-term opioid therapy for chronic non-cancer pain in the absence of clear and documented benefits to functional status and quality of life.

Choosing Wisely | AMDA (paltc.org)