For some older adults, hospitalization can be a pivotal event that changes their health trajectory after discharge. Poor health outcomes can result despite appropriate treatment for the primary reason for hospitalization. The risk is greatest for older adults with frailty, cognitive impairment, complex social situations, visual or hearing impairments, or multiple comorbid illnesses. These impart a special susceptibility to the hospital environment which often younger and healthier patients can withstand.
Successfully caring for hospitalized older patients requires that hospitalists examine a wide range of factors besides disease burden in medical decision-making.
II. Identify the Goal Behavior
Evidence-based recommendations exist for many clinical conditions; however, many studies excluded patients with advanced age and multiple comorbid conditions. Thus, when caring for geriatric patients, hospitalists must look beyond the disease-centric approach. In addition to disease-specific, evidence-based guidelines, clinicians should consider many factors, including: the interaction between treatments or interventions, the feasibility and complexity of the intervention, patients’ preferences and goals for medical treatment and quality of life, their estimated prognosis, and their multifactorial geriatric syndrome burden.
III. Describe a Step-by-Step approach/method to this problem.
Step 1: Conduct a complete review of the care plan before meeting with the patient and caregiver.
It is best to have a clear understanding of the following before proceeding:
Is the care plan indicated?
What is the evidence for efficacy in patients similar to the one you are caring for? If none, in what patient population has it been shown to be efficacious?
What assumptions are required to offer the care plan to your patient?
Taking into account patient characteristics, prognosis, side effects, and potential benefit, should the care plan be offered to the patient?
Step 2:Inquire about the patient’s (and family’s) primary concerns and objectives during their hospitalization. Older adults evaluate choices and prioritize preferences for care using personal and cultural values. Elicit what clinical outcomes are preferable as well as what outcomes the patient would want to avoid.
Step 3: Review the care plan with the patient and family.
Include a discussion of treatment options, duration, and burdens. It is important to describe the most likely outcomes over the long-term, beyond the hospitalization, when possible.
Discuss the applicability and quality of evidence recognizing that many studies exclude frail older adults.
Examine how the most likely outcomes may or may not match the patient’s desired outcome.
Address treatment feasibility and complexity. Evidence shows that more complex treatments lead to a higher risk of nonadherence and adverse reactions, poorer quality of life, increased economic burden as well as depression and increased fatigue in caregivers.
Step 4: Consider and discuss prognosis. Tools exist to help clinicians determine estimated prognosis. Offer to discuss prognosis with the patient and family as this may change outcomes they find acceptable. ePrognosis.com allows clinicians to review with their patients a graphical illustration of mortality risk.
Step 5: Weigh benefits and harms in the treatment plan.
Consider the ‘time needed to benefit’- does the intervention have a desired benefit within their expected lifetime? Equally important is consideration of the ‘time needed to harm’- can a harm occur sooner than a benefit or is it more dangerous or likely than a benefit in their expected lifetime?
Step 6:Inquire about and consider patient preferences.
Elicit patient preferences regarding treatment options only after the individual and their family or caregiver feel they have understood the information presented regarding the proposed care plan. Treatments choices can be framed and selected based on the likelihood of avoiding their least-desired outcome or the likelihood of attaining the patient’s most-desired outcome.
Step 7: Communicate and decide for or against implementation or continuation of intervention or treatment. Given the complexity of the decision, it is reasonable to ask the patient if they would like for you to make a recommendation. Use the above principles to recommend a treatment that optimizes benefit and preference, minimizes harm, and enhances quality of life.
Step 8: Reassess at selected intervals for benefit, feasibility, adherence, and alignment with preferences.
Over time patients’ preferences and prognosis may change, as well as the feasibility, benefits, and harms of interventions. Periodic reassessment of these issues realigns decision-making with patient goals along the trajectory of care.
IV. Common Pitfalls.
When discussing benefits and harms:Uncertainty may exist when discussing the likely outcomes of interventions. In addition, it is difficult to convey a clear, interpretable understanding of benefits and harms. During these conversations, it is best to convey your uncertainty with what you are discussing.
Applying clinical evidence:Many older adults have significant multi-morbidity and complex social and economic situations. It is often difficult to extrapolate findings from studies whose characteristics are outside the study population.
When estimating prognosis:In older adults with multiple diseases and complex social determinates, there is a degree of uncertainty even when using one of the available prognostic indices. In addition, particularly in those with multiple morbidities, one treatment may improve one outcome (e.g., mortality) but weaken another (e.g., functional status). In this case, multiple treatments must be considered simultaneously to determine which may give the most desired outcome overall.
V. National Standards, Core Indicators and Quality Measures.
No national standards/benchmarks established yet.
What's the Evidence?/References
“AGS Expert Panel on the Care of Older Adults with Multimorbidity.”. J Am Geratr Soc. vol. 60. 2012. pp. 1957-1968.
Tinetti, ME, Bogardus, ST, Agostini, JV. “Potential pitfalls of disease-specific guidelines for patients with multiple conditions.”. N Engl J Med. vol. 351. 2004. pp. 2870-2874.
Reuben, DB, Tinetti, ME. “Goal-oriented patient care—an alternative health outcomes paradigm.”. N Engl J Med. vol. 366. 2012. pp. 777-779.
Yourman, LC, Lee, SJ, Schonberg, MA. “Prognostic indices for older adults: A systematic review.”. JAMA. vol. 307. 2012. pp. 182-192.
Smith, AK, Williams, BA, Lo, B.. “Discussing overall prognosis with the very elderly.”. N Engl J Med. vol. 365. 2011. pp. 2149-2151.
Fried, TR, Byers, AL, Gallo, WT. “Prospective study of health status preferences and changes in preferences over time in older adults.”. Arch Intern Med. vol. 166. 2006. pp. 890-895.
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