It’s a conversation most of us are squeamish about having. But according to new recommendations by a team of physicians at the San Francisco VA Medical Center (SFVAMC) and the University of California, San Francisco, doctors should routinely discuss the overall prognosis with their elderly patients who have a life expectancy of less than 10 years or have reached age 85.
Such discussions would better help older patients make informed decisions about medical care, health priorities and life choices, said lead author Alexander K. Smith, MD, MPH, an SFVAMC physician. “In our experience, many older adults are aware that they are in life’s final chapter, so such a conversation would not come as a shock to them. As physicians, we have an obligation to give them honest information.”
The authors cite several studies in which a majority of elderly patients expressed a desire to discuss overall prognosis with their physicians. The recommendations appear in a “Perspective” in the December 8, 2011 issue of the New England Journal of Medicine.
“Very often, doctors will take prognosis into account when making clinical decisions, such as deciding whether to order a diagnostic test, but they tend not to discuss prognosis explicitly with their older patients,” said Smith, who is also a Greenwall Faculty Scholar in Bioethics and an assistant professor of medicine in the Division of Geriatrics at UCSF. “We feel that this is a missed opportunity for helping patients make informed medical decisions.”
For an 85 year old patient, with a life expectancy of six years, a frank discussion of prognosis might result in “a significant reordering of health priorities,” said Smith. “For example, maintaining mobility, putting financial affairs in order and preparing for long term care may take higher priority than screening for cancers or having really tight blood sugar control for diabetes.”
The “Perspective” authors note that the potential harms of many preventive health interventions are “immediate,” whereas the benefits might not accrue for years, “so clinical priorities should and do vary with life expectancy.”
Smith emphasized that there is evidence that a “substantial minority” of elderly patients do not want to discuss prognosis. “There are good reasons for that,” he said. “They may not be psychologically prepared, or it may run counter to a cultural perspective or belief. If possible, the physician might want to explore those reasons with the patient, but never force the discussion.”
Co-authors are Brie A. Williams, MD, a staff physician at SFVAMC and assistant professor of medicine at UCSF, and Bernard Lo, MD, professor of medicine and Director of the Program in Medical Ethics at UCSF. SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF. UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.
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