Right-sizing care of patients with serious illnesses

- Kenny Lin, MD, MPH

Concerned about the overuse of ineffective or harmful practices in older patients with serious illnesses, the High Value Task Force of the American College of Physicians (ACP) recently published a synthesis of best practices on patient-centered communication about serious illness care goals. Although these conversations can sometimes be uncomfortable for clinicians or patients, the authors offered several reasons that they should occur early and often:

An understanding of patients’ care goals in the context of a serious illness is an essential element of high-quality care, allowing clinicians to align the care provided with what is most important to the patient. Early discussions about goals of care are associated with better quality of life, reduced use of nonbeneficial medical care near death, enhanced goal-consistent care, positive family outcomes, and reduced costs. Existing evidence does not support the commonly held belief that communication about end-of-life issues increases patient distress.

What clinical situations should trigger discussions about end-of-life preferences? The authors recommended making time for a conversation in the setting of worsening symptoms or frequent hospitalizations in patients with COPD, congestive heart failure, and end-stage renal disease; in all patients with non-small cell lung cancer, pancreatic cancer, and glioblastoma; in patients older than 70 years with acute myelogenous leukemia; in patients receiving third-line chemotherapy; and in hospitalized patients older than 80 years. The ePrognosis website offers useful tools for clinicians to estimate prognoses in older persons with serious illnesses.

According to the ACP, key elements to address in these conversations include understanding of prognosis; decision making and information preferences; prognostic disclosure; patient goals; patient fears; acceptable function; trade-offs; and family involvement. Additional guidance for discussing end-of-life care and eliciting patient preferences has been published in American Family Physician and Family Practice Management. Previous AFP Community Blog posts have also discussed misconceptions about palliative care, progressive disability in older adults, and gaps in end-of-life planning.