Making Wise Healthcare Decisions: Five Things Physicians and Patients Should Question

Encouraging our older patients—and their family caregivers, when appropriate—to play active roles in both their health and their healthcare decisions is an integral part of our role as their healthcare providers. When it comes to evaluating treatment options for older people, there are typically more “unknowns” than one encounters with younger patients. The fact that older patients may respond differently to treatments than younger adults, but are significantly underrepresented in clinical trials, accounts for this in part; so does the fact that three out of every four adults aged 65 years and older have multiple chronic health problems and may take multiple medications that can interact with one another in differing ways. In light of this, it is particularly important that older people and their healthcare providers thoroughly discuss the potential benefits and drawbacks of both medical tests and treatments.

Encouraging patients to learn about and discuss these issues with their healthcare professionals is also the goal of the groundbreaking Choosing Wisely^® campaign that the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports launched in 2011. Through the Choosing Wisely campaign, the ABIM Foundation partners with medical societies to identify five tests or treatments for which there may not be sufficient evidence of safety or effectiveness, and posts these lists of “five things” on the campaign Website, www.choosingwisely.org. Then the ABIM Foundation, the participating society, and Consumer Reports encourage laypeople to check whether tests or treatments their healthcare providers have recommended are on the lists. If so, patients are encouraged to bring this up with their healthcare professionals and discuss it.

The first group of medical societies that the Foundation invited to identify their “five things” did so last year. In late February, the campaign posted its second set of lists, which were taken from the American Geriatrics Society (AGS) and 16 other medical organizations, to the campaign Website. 

The AGS’s list, along with accompanying professional and public education materials, can also be found on the society’s Website, www.americangeriatrics.org, and an article about the development of the list has been published in the Journal of the American Geriatrics Society online. Its “five things” include the use of feeding tubes for older patients with advanced dementia as well as the prescribing of antipsychotic drugs for aging patients with behavioral and psychological symptoms of dementia. Also on the AGS’s list are efforts to achieve tight glycemic control in complex older adults with diabetes; the prescribing of benzodiazepines and other sedative-hypnotic drugs for elderly patients with insomnia, agitation, or delirium; and the use of antimicrobial medications in the treatment of older patients without specific urinary tract symptoms. 

If you have not already done so, I urge you to refer your patients to the society’s list and to the series of easy-to-read “Ask the Expert” articles about each of the society’s “five things” that the AGS Foundation for Health in Aging has posted at www.healthinaging.org. The society and Consumer Reports are also planning to collaborate on another public education resource focusing on one of the five listed treatments. I hope the AGS’s “five things” in particular, and the Choosing Wisely campaign in general, will prompt healthcare providers and older patients to question other tests and treatments by asking, “Is this really safe and appropriate, and will any potential benefits outweigh any harms that may be associated with it?” Such discussions should be part of a comprehensive discussion about each patient’s plan of care and how to optimize it. 

These discussions can be most productive if clinicians follow basic elements of effective health communication and health literacy. These elements include using plain language, slowing down when speaking, and “breaking it down” into easily understandable concepts. At the end of such discussions, highlighting the two or three most important concepts, and then checking for understanding of these—by asking patients to repeat, in their own words, what they need to know or do—is also important. 

There has been much in the medical literature about “patient activation”—that is, helping patients take more ownership, responsibility, and control over their health and healthcare. Such discussions can go a long way toward that goal. Among other things, research has found that patients who are “activated” have better care outcomes and care experiences, and that healthcare professionals caring for such patients report greater satisfaction.¹

The goals of care for older adults are varied and it is imperative to remember that preserving function and quality of life may be more important than longevity in many cases. That said, each older adult may see the “time trade-off” differently, and this needs to factor into decisions as well; so do the influences of ethnicity, culture, and other demographic factors that will affect how discussions proceed and how decisions are reached.

Reference

1. Hibbard JH, Greene J. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. HealthAff. 2013;32(2):207-214.