Shared decision making in the golden years

by Mary McNaughton-Collins, MD, MPH

Aging does not have to be all about appointments, pills, tests, treatments and procedures – instead aging should be about celebrating life and rewarding those older individuals who are “living well” by encouraging pursuits outside of the medical realm.

The current state of our health care system tends to revolve around the idea that “more is better,” however, that is not always true — especially when caring for those 65 and older. Therefore, what our country needs is a paradigm shift — one that will truly take into consideration the benefit to a patient’s quality of life and longevity.

Older patients face many competing risks of death and the absolute effect of a new diagnosis on one’s longevity may be very small. Deciding to act upon a new diagnosis could in fact do more harm than good — there is a strong correlation between age and treatment-related risk.

Shared decision making, the collaboration between provider and patient in making a medical decision, is becoming a more widely used process in health care. But it is even more important for a provider to engage in shared decision making with a patient who is in their “golden years”.

By engaging in shared decision making, the provider will learn what the elderly patient’s short-term and long-term plans are, the patient’s values and preferences, and ultimately what the patient wants. Depending on factors of competing risks and the knowledge gained through the process of shared decision making, a patient may decide against an intervention- and even if you as a provider do not agree with this decision, using terminology such as “reluctant” or “refused” in your report of that visit is unfair- a patient has the right to say “no thanks”.

As a primary care physician, I have seen first-hand how important shared decision making is when caring for my elderly patients. Some examples are:

Mr. A, spry and vibrant at the age of 90, fainted while he was playing cards while visiting with his brother in another state. He was admitted to the hospital and told by the cardiologists that he needed an implantable defibrillator or he would die a ‘sudden death’, possibly just walking across the street after leaving the hospital. Mr. A decided to decline the device due to his age and lack of information about the pros and cons; however, it took courage to say “no” as he was being pressured to have the device by the cardiologists. He made an appointment to see me once he returned home and we reviewed his condition at which time we also took into consideration his quality of life and age.  I supported his informed decision to decline the device. Ten years later, Mr. A is alive and well.

Mrs. B, married almost 60 years, with lots of devoted children, grandchildren, and great-grandchildren, suffered a stroke. She survived a prolonged hospital and rehab course, and was thrilled to be home again, making excellent progress with minimal deficits. Her evaluation revealed a hole in her heart as the likely cause of her stroke and she was seen by multiple specialists including a cardiothoracic surgeon who recommended fixing the patent foramen ovale. The patient made an appointment with me to discuss this decision as she did not want to go back to the hospital for anything, never mind a surgical procedure. When asked what she was looking forward to, she replied she had an upcoming 60th wedding anniversary that her family planned. I supported her informed decision to decline the procedure, although I received reports from my specialist colleagues expressing concern with her “refusal” and “reluctance”. Mrs. B had a wonderful anniversary, and 2 years later continues to enjoy time with her husband and family.

Mrs. C, a frail woman in her late 80’s suffered from a small stroke.  While in the hospital, the neurologist reflexively doubled her statin dose. Mrs. B returned days later with GI symptoms and was re-admitted. Turned out the side effects of the double dose statin was the issue. She made an appointment to see me in follow-up and we discussed her feelings toward the higher dose. Mrs. C, never keen to take medications, expressed that she felt much better on the low dose and did not want the double dose as the neurologist had advised. If shared decision making had been used during her first hospitalization, the second could have been avoided.

As health care providers we have a responsibility to take our patients’ best interests to heart instead of abiding by the trend to just write one more prescription, order one more test or refer for one more procedure. The mindset of adding just one more medical intervention can be the difference between an older patient enjoying the rest of their life or living over-medicalized.

Mary McNaughton-Collins is the medical director at the Foundation for Informed Medical Decision Making in Boston. She is also a primary care physician at Massachusetts General Hospital.

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