November 26, 2018 03:59 pm Sheri Porter – Family physicians care for patients of all ages, and many say it's that cradle-to-grave concept that draws them to the specialty. However, talking with patients about life expectancy can be difficult for even the most seasoned primary care physicians.
This reluctance is seen even as clinical practice guidelines increasingly urge physicians to incorporate life expectancy into decisions about preventive care for older adults.
An article(www.annfammed.org) titled "Older Adults' Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey" published in the November/December issue of Annals of Family Medicine tackles the topic head-on in an attempt to discover what patients think.
Researchers surveyed more than 800 adults age 65 or older about physician/patient discussions on life expectancy. Participants were given information about a hypothetical patient -- one who was not in imminent danger of dying but did have a limited life expectancy -- and then were asked to respond to a series of questions as if they were in that situation.
Would they want to have a conversation with the doctor about how long they might live? Was it OK for the doctor to bring up this subject? Should the doctor talk to their family and friends about life expectancy? When should the doctor broach this topic?
A majority of survey participants, 59.4 percent, said they would not want to discuss how long they might live. Of those respondents, 59.9 percent did not think it was appropriate for the physician to raise the topic, and 87.7 percent would not want the doctor to have that life expectancy conversation with their family or friends.
Timing was also a key issue; 55.8 percent of respondents were amenable to having the discussion with a physician only when life expectancy was two years or less.
"We found that the longer the hypothetical patient was expected to live, the smaller the proportion of participants who wanted to discuss life expectancy," wrote the authors. "A sizable minority (16.5 percent) did not wish to have this discussion even when it was one month." On the other hand, about 11 percent were OK with discussing life expectancy even when it was 20 years.
Corresponding author Nancy Schoenborn, M.D., an assistant professor of medicine in the geriatric medicine and gerontology division at Johns Hopkins University School of Medicine in Baltimore, told AAFP News the topic was both important and timely.
Aside from concerns about adherence to clinical guidelines, Schoenborn noted the growing interest in palliative care and in taking patient preferences into consideration. She recalled stories about very sick patients who were admitted to the hospital and had those end-of-life conversations in the midst of a crisis with unfamiliar doctors.
"Wouldn't it be better for patients to have these discussions earlier upstream with their regular doctor who knows them better? But no one has really defined how much more upstream," said Schoenborn.
As an internist and gerontologist, Schoenborn looks at the issue from a primary care perspective.
"Although everyone can probably get behind the notion these are important conversations to have, it's difficult to implement them in primary care, where there's a lot of time pressure. We need a trigger to prompt these discussions," she said.
But the timing has to be right.
"Sometimes these patients are sick but stable, and they're just here for a follow-up. And all of a sudden, having this discussion about how long they might be expected to live blindsides them."
Schoenborn said the research results highlighted patient characteristics that could help inform physicians as to when a patient might be receptive to the topic.
"We found that patients who'd had what they considered a life-threatening illness, those who think doctors can predict life expectancy and those who have discussed the life expectancy of a loved one are much more likely to be open to these discussions," she said.
Schoenborn specifically treats adults 65 and older. "This is what I do every day. My patients often talk about being a caregiver for another family member or tell me if there's been a recent death in their family." Hearing that type of information can provide a starting point for physicians to ease into a conversation about a patient's preferences regarding his or her own situation, she said.
Schoenborn pointed out what all physicians know: Patients of the same age can have wide variations in their health and functional status.
Referencing her patient panel, Schoenborn said, "One patient could be running a marathon while another is homebound and needs help with everyday activities. And so, we need to try to individualize the decisions we make."
Clinical guidelines are based on good intentions and good evidence, but the survey results show the concept and wording of life expectancy itself does not resonate with patients. "We have to find a way to present that same idea to patients in a more acceptable way," said Schoenborn.
She said this topic of life expectancy discussions with patients is much debated among geriatric medicine researchers like herself, and she has encountered colleagues who share stories about the eagerness of their patients to engage in such discussions.
The key takeaway, said Schoenborn, is not that patients never want to hear this information; rather, physicians must be aware of the variation in patient attitudes on this topic.