Every primary-care physician
who cares for elderly patients faces hard decisions. But among the hardest of choices a doctor makes, especially with the sickest of the sick, involves long-term care.
Should doctors initiate, in advance of urgent need, discussions of the options available—home healthcare, assisted-living facilities and nursing homes—face to face with those patients? And if the answer is “yes,” when and how should they have that conversation?
Unless a health crisis prevails, physicians all too often skip having this conversation.
The reasons physicians are reluctant to discuss long-term care with patients, and infrequently do so, are manifold. Physicians are seldom trained to conduct such momentous conversations with patients, or at best are prepared only peripherally. We are also inherently conservative and slow to adapt to change. We typically think and act short term, in response to episodes along the care continuum, rather than long term.
But perhaps the more overwhelming barrier is psychological. After all, such heart-to-heart conversations promise to be difficult, both for physician and patient, and often create discomfort. We care about our patients. But too often patients live in a degree of denial. Few want to confront the issue of long-term care—so often a precursor of mortality.
All of us also are unduly optimistic about how long we're going to stay healthy. We hesitate to accept the incontrovertible fact that all of us ride a trajectory that ultimately reaches an endpoint.
Similarly, bringing up long-term care with patients can seem the equivalent of delivering a poor prognosis. We worry that offering such guidance will leave our patients depressed, even hopeless. We perceive long-term care, mistakenly, as an admission that we've failed our patient. Instead, we often wait for patients to raise the issue.
So if we can avoid this conversation, chances are we will. And in doing what we believe to be right, we're actually committing a wrong.
Bypassing this conversation can have serious consequences. Patients who need to be alerted to and educated about long-term care may be ill-informed and even ignorant about the choices available and what those choices might mean. Chronic health issues that could be prevented from progressing may worsen. Such inaction could increase emergency room visits and hospital admissions and drive healthcare costs higher. The medical community as a whole has to change this equation, and soon.
Current healthcare reform initiatives touch only minimally on this undercurrent. Yet, with an estimated 70% of Americans over age 65 now expected to require some kind of long-term care, this conversation will be increasingly pivotal.
I've seen the price we pay for avoiding this physician-patient dialogue, first for 29 years as a practicing family physician and now as CMO with a company that supports long-term care. I've studied the issue, given lectures about it and promoted continuing education efforts for physicians.
Here, then, is my blueprint for physicians to kick-start this all-important conversation:
Act early rather than after the fact. Doctors too often delay the inevitable until a health crisis emerges. Hasty action required at the 11th hour may lead to poor decisions about the next steps. Discuss while it's voluntary rather than mandatory.
Do it with delicacy, diplomacy and dignity. Talk in the right setting—privately and never, say, in a hospital corridor—and at the right time, when all parties are relaxed and receptive. Involve family members. Gently set the stage. As in: “It's time for us to have a talk. I know this is difficult. But let's do it for your benefit.”
Understand the patient's goals. To minimize pain? Live independently? Take into account how best to meet those goals. Rather than treat diseases, as we're trained to do, we must be patient-centric.
Improve medical education. Universities should develop and implement a curriculum that encompasses training about the role and value of long-term care, including how to talk with patients about it.
No one in the healthcare system is better equipped to take responsibility for coordinating long-term care
for patients than the primary-care physician. I urge my fellow practitioners, on behalf of our aging population, to commit fully to thinking long term.