April 15, 2012 - No one wants to consider their own mortality—their final chapter
. Yet, as it’s been said, no one leaves this world alive. As we grow older, this subject becomes more and more relevant and has recently been highlighted, as medical care for the elderly becomes more efficacious and expensive.
“Discussing Overall Prognosis with the Very Elderly,” is the subject of a recent New England Journal of Medicine
perspective, which stated: “Very often, doctors will take prognosis into account when making clinical decisions such as deciding whether to order a diagnostic test, but they tend not to discuss prognosis explicitly with their older patients.” Everyone, young and old should understand their illness, treatment and prognosis.
Unfortunately, medical prognosis
—what may well happen—is too frequently a forgotten subject, as opposed to diagnosis or treatment. This lack of focus on the future may be a defense mechanism—namely denial—or just too difficult to measure.
Everyone is generally better off having more information than less, even if the information is not as precise as we would like. There is a wide range of life expectancy which has been quantified for large groups or cohorts of people in America each year (http://www.cdc.gov/nchs/fastats/deaths.htm
The average 85 year old can expect to live another six years. But no one wants to consider themselves “average”. Everyone typically underestimates their own medical problems and overestimates their abilities to resist disease and illness. An average 85 year old has a 75 percent chance of living another three years, and a 25 percent chance of living 10 years, according to recent demographics. Importantly, most folks are very optimistic about the future—an effective coping mechanism and we don’t want to mitigate this hope.
Understanding possibilities and probabilities
helps in effective planning. An exercise in futility, for example, is screening an elderly man for a disease which takes years to develop, such as prostate cancer. In an 85 year old with a much shorter life expectancy, screening makes no sense and wastes a valuable resource, namely Medicare funds. These resources could be better used to improve a patient’s current life style, such as enhanced mobility, better nutrition, or planning financially for the next generation by improving our educational system.
The same thought process is true with screening mammograms or Pap smears in women over 80. Without symptoms or signs of abnormalities the cost and false positive results are worthless for society and potentially harmful to the individual. Treating osteoporosis, improving balance, fall- proofing a residence, have much greater value for women in this category.
Empowering patients when they are well, cognitively intact, and have options is much better than waiting for a stressful end of life situation to bring up a discussion about prognosis. NCH’s hospitalists and intensivists—intensive care specialists—have these discussions for the first time with patients who are not in optimal condition to make thoughtful, measured, non-hurried important decisions. While this is necessary, because the subject has never been raised before, the optimal time is not right after a ride to the emergency room in an ambulance.
Interestingly, according to a Journal of General Internal Medicine
article based on interviews with sixty individuals averaging 78 years of age and in various states of health, two thirds expressed the desire to be told if they were thought to have less than five years to live. Spending time with children, family, and friends could be substituted for undergoing more procedures, taking more medications, and having potentially more time in a hospital.
Not everyone wants to know
—and this reaction is fine too. Simply having a patient state, “Don’t tell me my prognosis,” is always an option. Families might not want to know either, in which case they just have to come to an agreement with the patient and all of the care givers.
The most important point of this whole subject is we now have a better, though not perfect, way of predicting life expectancy. We can be accurate for large groups of patients and while we also know we will sometimes be wrong, we will still be within a range. Having information is usually better than being in the dark when it comes to planning a more successful future.