Not so long ago, it was common for doctors to keep sick patients, even terminally ill patients, in the dark about their prognosis. Today, many patients are actively involved in managing their illnesses, in partnership with their doctors. Indeed, one of the tabs on this blog is "You're the Boss."
But a "Perspective" in today's New England Journal of Medicine says doctors have shied away from explicit conversations about prognosis with a group of patients they should engage--the very elderly. The writers recommend doctors discuss "overall prognosis" with elderly patients who have a life expectancy of less than 10 years or who are 85.
If you're thinking that conversation sounds a bit, well, unpleasant, research shows that a majority of elderly patients want to have the information. In one study, 55 percent of frail elderly patients whose doctor had never discussed their prognosis wanted to. In a second study, albeit a small one with 60 people including disabled African-American, Chinese-American, Latino and white patients, 65 percent said they would want to be told if they had less than five years to live.
The recommendations come from a team of doctors in the Division of Geriatrics at UC San Francisco and the San Francisco VA Medical Center. "People want to know not just for medical reasons," said Dr. Alexander Smith of the San Francisco VA, one of the authors, "but because they want to make life choices, put financial affairs in order, arrange for a durable power of attorney for health care and think about longterm care."
Smith is a palliative care physician, someone who is trained in talking with patients about challenging medical news. He acknowledged that it is a skill to have these conversations. But for many elderly patients, information about lifespan is not a surprise. "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."
Of particular concern is the risk of many medical interventions, including screening tests. The writers cite a specific example of colonoscopy, an invasive procedure where the benefits may not be seen for years, benefits the patient may not live to see.
"This is really about empowering patients," Smith said, "giving patients information so they can make informed choices."
Still, doctors must tread carefully. While a majority of surveyed patients did want prognostic information, a sizable minority did not. Doctors should not force the discussion, the writers say.