The explosion of medical research and new knowledge continues, providing scientific bases to either support interventions recommended by doctors or demonstrate their ineffectiveness. The availability of this data, and the myriad opinions that accompany it, permeate the internet and inform the general public about ways to approach medical problems. So much information can be challenging to navigate for both patients and physicians.
The approach to medical decision making has evolved over the decades. When confronted with medical recommendations and decisions, most individuals have relied on the knowledge and experience of their doctors to determine what course would be best for them to follow. This follows the traditional role of physicians as the final determinant for “what is best” for the person they are treating.
[See: How to Help Aging Parents Manage Medications.]
Now, the approach to medical decision making is becoming more of a shared process. Decisions that have often involved just the doctor and patient now may involve family members and caregivers — all with varying opinions of how to approach a medical problem. Goals of medical decisions have traditionally revolved around sustaining life or adding years of life. More nuanced choices have developed around issues of quality of life, not just around “staying alive.” Quality-of-life goals are very individualized — and not necessarily the targeted goals of the published medical trials that often form the scientific basis of medical decisions.
A set of recommendations have been developed by multiple medical societies to foster the quality-of-life discussion between patients and physicians. The Choosing Wisely campaign was developed by the American Board of Internal Medicine Foundation to address issues and questions that often arise in patient care and to help provide scientific guidance for physicians making medical recommendations. Its recommendations can be reviewed at choosingwisely.org.
Additionally, the American Geriatrics Society has provided a set of 10 recommendations for physicians related to the quality-of-life care of older individuals. The list is as follows:
1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
2. Don’t use antipsychotics as the first choice to treat behavioral and psychological symptoms of dementia.
3. Avoid using medications other than metformin to achieve hemoglobin A1c less than 7.5 percent in most older adults; moderate control is generally better.
4. Don’t use benzodiazepines or other sedative-hypnotics in older adults as the first choice for insomnia, agitation or delirium.
[See: 11 Things Seniors Should Look for in a Health Provider.]
5. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.
6. Don’t prescribe cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
7. Don’t recommend screening for breast, colorectal, prostate or lung cancer without considering life expectancy and the risks of testing, overdiagnosis and overtreatment.
8. Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, discontinue medications that may interfere with eating, provide appealing food and feeding assistance, and clarify patient goals and expectations.
9. Don’t prescribe a medication without conducting a drug regimen review.
10. Don’t use physical restraints to manage behavioral symptoms of hospitalized older adults with delirium.
[See: 5 Ways to Cope With Mild Cognitive Impairment.]
The rationale behind these recommendations revolves around multiple issues confronted by older persons, including appropriate management of common medical problems (such as diabetes and urinary tract infections), how to approach end-of-life concerns (like feeding tubes) and how to approach problems related to care of these individuals while in the hospital setting (delirium). The recommendations are not all-encompassing. It would be impractical and impossible to address every single potential issue or question that could come up in discussions between patients and their physicians. They do, however, provide an excellent example of how free communication and a unified set of goals between physicians, their patients and families can develop a plan of care that everyone is comfortable with.
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Choosing Wisely: With Your Physician originally appeared on usnews.com
