Executive Summary
Clinicians often make inaccurate assumptions about older adults’ goals and cognitive capacity. This can lead to unwanted aggressive care or undertreatment. To ensure ethical care according to experts, providers should:
• Make value-based decisions about interventions.
• Don’t assume older patients are cognitively impaired.
• Order screening tests based on the individual patient’s values, goals, and overall health.
Many excellent physicians spend a significant amount of time with their older adult patients, explaining health issues in an understandable and compassionate fashion and answering questions as needed.
“However, just like in our general society, physicians may also hold certain stereotypes about their older patients,” says Susan Peschin, MHS, president and CEO of the Washington, DC-based Alliance for Aging Research.
Some physicians assume the older adult’s goals are just like theirs. “Most physicians are much younger than the older adult patient. There is a culture gap that goes unrecognized,” says Joshua Uy, MD, clinical assistant professor of medicine in the Division of Geriatric Medicine at Penn Medicine in Philadelphia.
The younger physician might assume that all older patients want to live as long as possible with aggressive treatment, he says. “This is true for some adults. For others, the quality of life is not worth living and all they want is palliative care,” says Uy. Conversely, if physicians assume that the older person’s quality of life is not worth living, patients are denied effective, desired care.
A frail 95-year-old man’s cardiologist told him that an implantable cardioverter defibrillator would help his heart — without explaining that the device wouldn’t slow down the disease process or repair existing damage to the heart. “The patient ended up having this $35,000 device placed, and came home,” says Uy. He explained the device’s purpose to the man: To resuscitate him when his heart went into a fatal arrhythmia. “This gentlemen was actually OK with passing away. He had a very difficult life,” says Uy. “By not discussing the values of the intervention, it didn’t let him participate in whether he wanted it.”
Physicians are generally focused on whether a patient needs a specific intervention; they fail to ask the question, “To what end?” “The recognition of it as a value-based decision — that there could be more than one right answer — is not even there,” Uy says. “I hate to say it, but physicians are better at treating numbers than they are at listening to patients, probably.”
This leads to older patients sent for cancer screenings even though they are dying of heart disease. “It’s easier to just order the test and talk about how smoking history is an indication for screening for lung cancer,” says Uy. “It’s a lot more difficult to say, ‘How would it help this specific patient in terms of their values, their goals, and their overall health?’”
On the other end of the spectrum, many physicians stop ordering mammograms, colonoscopies, and Pap smears based solely on guidelines that recommend stopping these screening tests at certain ages. “There is nothing magical that happens at 75. It’s an arbitrary cutoff for when things go from being more effective to less effective,” says Uy.
Instead of considering the patient’s individual situation and having the patient participate in the decision, physicians simply don’t order the screening. “What comes across to the patient is, ‘My doctor doesn’t care if I get cancer anymore,’” Uy says.
Some patients in their 90s ask for mammograms; if so, Uy asks them, “What are you hoping for? What are your fears?” The patient might say, “I’m afraid of getting cancer,” which then opens up the opportunity for a discussion about their goals and values.
“The problem is that physicians need to communicate not in terms of guidelines and physiologic terms, but by putting recommendations in context of the patient’s values and goals,” says Uy. “To me, that is what would make it an ethical decision.”
Some providers automatically switch to “baby talk” when communicating with older adults, says Jason Karlawish, MD, professor of medicine, medical ethics, and health policy at the University of Pennsylvania in Philadelphia.
“In taking on the tone of voice one might use with a child, you are essentially conveying a view about the patient’s capacity, and your feeling of pity or even disgust for them,” he says. The provider’s tone of voice gets in the way of effective communication and decision-making, he says.
“It can affect the information and choices you present,” says Karlawish. “Any older adult who is ill in bed will look pretty vulnerable and sick, even those with no cognitive impairment.” He tells residents to imagine Supreme Court Justice Ruth Bader Ginsburg with pneumonia in the hospital, and tells them, “I certainly hope you wouldn’t be baby-talking Justice Ginsberg.”
The first step is for clinicians to consider how their tone of voice affects the way they think about and make decisions about an older adult. “Taking on a gentle tone of voice might be appropriate. But the default is, you should talk to older adults as you talk to other adults,” he says.
Physicians sometimes make blanket assumptions about what’s typical at certain ages, such as decreased cognitive function or kidney function; this might not reflect the patient before them. “As clinicians, we want to recognize that there is substantial variability between older adults,” says Karlawish. “One must see how well the individual fits within that range of what is expected.” Here are some factors contributing to undertreatment of older patients:
• Providers may question the point of diagnosing and initiating symptomatic-only treatment, if there is no cure.
In some cases, says Peschin, “there is a nihilistic attitude regarding identification and intervention for older patients.”
• Providers may assume that older patients don’t want to know if they have a serious condition such as dementia.
“Literature on this issue shows that most older patients and their family caregivers experience a sense of relief in finally knowing, and being able to prepare for what is down the road,” says Peschin.1
• Providers may not choose to intervene, even in cases where the intervention has been found to be curative.
“Older patients sometimes face the ‘We all have to die of something’ perception,” says Peschin. “A good example of this is valve disease, which can lead to loss of independence, disability, and even death.” Older women are often misdiagnosed as having anxiety rather than valve disease, and do not get appropriate treatment.2
“When diagnosed correctly, repair and replacement — the most effective treatments for most valve diseases — have very high success rates, and in most cases improve quality of life and add many more healthy years,” says Peschin.
• Negative stereotypes about patients can impact access to intervention with atrial fibrillation.
“While oral anticoagulation is highly effective at reducing stroke risk, elderly patients are often under-anticoagulated,” says Peschin. Healthcare providers tend to prioritize bleeding risk over stroke prophylaxis in older patients. “Providers also harbor misperceptions over falls and bleeding risk — that the older patient will fall and experience a fatal brain bleed — which, in reality, is highly unusual,” says Peschin.
Peschin says bioethicists can play a significant role in debunking common stereotypes that healthcare professionals may have about their older patients. Providing continuing medical education programs is one way of doing this. “These are a good opportunity for bioethicists to capture the attention of physicians, and to test for changes in attitude before and after,” she suggests. Educational programs might cover attitudes about geriatric cardiac patients, the benefits of truth-telling with dementia patients, and positive clinical approaches to older patients. Bioethicists can also publish opinion pieces on these topics. “This can serve to ‘move the needle’ on commonly-held beliefs and practices that need to change,” says Peschin.
References
- Carpenter BD, Xiong C, Porensky EK, et al. Reaction to a dementia diagnosis in individuals with Alzheimer’s disease and mild cognitive impairment. J Am Geriatr Soc 2008; 56(3):405-412.
- Chiaramonte GR. Gender bias in the diagnosis, treatment, and interpretation of CHD symptoms: Two experimental studies with internists and family physicians. Presented at the Transcatheter Cardiovascular Therapeutics scientific symposium. October 12, 2008.
SOURCES
- Jason Karlawish, MD, Professor of Medicine, Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia. Phone: (215) 898-8997. Fax: (215) 573-8684. Email: [email protected].
- Susan Peschin, MHS, President and CEO, Alliance for Aging Research, Washington, DC. Phone: (202) 688-1229. Fax: (202) 955-8394. Email: [email protected].
- Joshua Uy, MD, Clinical Assistant Professor of Medicine, Division of Geriatric Medicine, Penn Medicine, Philadelphia. Phone: (215) 662-2746. Fax: (215) 349-5648. Email: [email protected].
Clinicians often make inaccurate assumptions about older adults’ goals and cognitive capacity. This can lead to unwanted aggressive care or undertreatment.
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