Discussing Overall Prognosis with the Very Elderly
Division of Geriatrics, Department of Medicine, University of California, San Francisco, USA. New England Journal of Medicine
(Impact Factor: 55.87).
12/2011; 365(23):2149-51. DOI: 10.1056/NEJMp1109990
Though life expectancy inexorably decreases with advancing age, we tend to avoid discussing overall prognosis with elderly patients who have no dominant terminal illness. But we may thereby undercut patients' ability to make informed choices about their future.
Available from: Jan Schuling
- "However the number of studies is limited and concerns younger patients in a different setting. Our study focuses on settings that offer an opportunity for discussion on ‘modification of targets for chronic disease management’ and ‘reducing burden of medication’ or ‘life choices’ . Patients as well as caregivers indicated that they would use a shared decision making instrument in clinical encounters and attributed multiple functions to the instrument, especially as a tool to facilitate agreement on treatment goals and plans . "
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ABSTRACT: Elderly patients with multimorbidity who are treated according to guidelines use a large number of drugs. This number of drugs increases the risk of adverse drug events (ADEs). Stopping medication may relieve these effects, and thereby improve the patient's wellbeing. To facilitate management of polypharmacy expert-driven instruments have been developed, sofar with little effect on the patient's quality of life. Recently, much attention has been paid to shared decision-making in general practice, mainly focusing on patient preferences. This study explores how experienced GPs feel about deprescribing medication in older patients with multimorbidity and to what extent they involve patients in these decisions.
Focusgroups of GPs were used to develop a conceptual framework for understanding and categorizing the GP's view on the subject. Audiotapes were transcribed verbatim and studied by the first and second author. They selected independently relevant textfragments. In a next step they labeled these fragments and sorted them. From these labelled and sorted fragments central themes were extracted.
GPs discern symptomatic medication and preventive medication; deprescribing the latter category is seen as more difficult by the GPs due to lack of benefit/risk information for these patients.Factors influencing GPs'deprescribing were beliefs concerning patients (patients have no problem with polypharmacy; patients may interpret a proposal to stop preventive medication as a sign of having been given up on; and confronting the patient with a discussion of life expectancy vs quality of life is 'not done'), guidelines for treatment (GPs feel compelled to prescribe by the present guidelines) and organization of healthcare (collaboration with prescribing medical specialists and dispensing pharmacists.
The GPs' beliefs concerning elderly patients are a barrier to explore patient preferences when reviewing preventive medication. GPs would welcome decision support when dealing with several guidelines for one patient. Explicit rules for collaborating with medical specialists in this field are required. Training in shared decision making could help GPs to elicit patient preferences.
BMC Family Practice 06/2012; 13(1):56. DOI:10.1186/1471-2296-13-56 · 1.67 Impact Factor
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ABSTRACT: Emergency department use contributes to high end-of-life costs and is potentially burdensome for patients and family members. We examined emergency department use in the last months of life for patients age sixty-five or older who died while enrolled in a longitudinal study of older adults in the period 1992-2006. We found that 51 percent of the 4,518 decedents visited the emergency department in the last month of life, and 75 percent in the last six months of life. Repeat visits were common. A total of 77 percent of the patients seen in the emergency department in the last month of life were admitted to the hospital, and 68 percent of those who were admitted died there. In contrast, patients who enrolled in hospice at least one month before death rarely visited the emergency department in the last month of life. Policies that encourage the preparation of patients and families for death and early enrollment in hospice may prevent emergency department visits at the end of life.
Health Affairs 06/2012; 31(6):1277-85. DOI:10.1377/hlthaff.2011.0922 · 4.97 Impact Factor
Available from: onlinelibrary.wiley.com
Journal of the American Geriatrics Society 10/2012; 60(10):E1-E25. DOI:10.1111/j.1532-5415.2012.04188.x · 4.57 Impact Factor
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