September 6, 2013

Doctors Often Bail on Care Discussions with the Elderly

Is it because many doctors are uncomfortable in geriatric medicine as they are uncomfortable in talking diabetes? I would have to say, yes! Is it important to reduce the risk of one ailment if it increases the risk of another? There are doctors that do just this and often don't realize they are doing this.

Clinicians or physicians very seldom engage patients, families, and especially caregivers in goals of care discussions about anything. These doctors rely instead on what they “know” to be in the best interest of the patient when in fact they are being disagreed with in many cases. What some of these doctors don't understand is that once they leave the office, the families or caregivers are talking about the appointment and how the doctor blew them off.

At least John Carney, President & CEO Center for Practical Bioethics is concerned about what these doctors need to consider. This underscores how we, as patients, need to broaden the goals of care discussion to aspects of our lives that include important considerations that go well beyond specific interventions. Goals of care conversations need to include topics like quality of life, comfort and functional status.

Two out of three seniors over 60 have two or more chronic conditions and under half have three or more. This means that many patients face these considerations. Here is where we need to help the physicians understand what our goals are and to some extent the factors that need to be weighed for our benefit. This is an important consideration if we are already using caregivers. Therefore, caregivers do not let the doctors bully you into what they think is best for us. Yes, the doctors need to assess, if they even know how, how the patient is doing if they have dementia. Is being observant the best approach, or is some action necessary?

We, as the patient, our families, or our caregivers need to raise the concerns about what is best for us with the doctors. Then if the doctor will not participate in the discussion, maybe it will be necessary to find a different doctor. Finding a solution that is clinically expedient or that meets some prescribed pathway should be avoided and should be something that reflects the values, preferences, and goals that will satisfy the needs of the patient.

Ethical issues can be raised in the discussion about advances in medical treatment as long as the discussion is a two way street. This means that the decision is a shared one based on the values of the patient. Do not go into hypothetical discussions, but talk about real issues in real time involving real life. Then formulate a plan that clearly reflects the goals of the patient.

Patients, family members, and caregivers that have an investment in achieving a shared outcome will work harder together to make it happen. Doctors that operate in a “best interest of the patient concept” may just find that they have done more harm than good because the patients, their families, or their caregivers have not bought into the “best interest” plan.

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