Dr. Alexander Smith, an assistant professor of geriatrics at UCSF, said giving elderly patients a sense of what lies ahead can help them decide which medical care to pursue or forgo and when it’s time to put their affairs in order.
As an example, he tells of a man in his mid-80s who sought hospital care recently after a nasty fall, only to discover that he had a slow growing cancer. When Smith asked the patient what he believed would happen, the man said he planned to beat the cancer and live to the age of 100. Smith told the man gently that his remaining time might be shorter than that and asked if he wanted details. The patient said yes, and fell silent when told that he might have months or a few years to live. Soon after, the man rewrote his will and prepared a durable power of attorney for his legal and medical affairs.
Although many patients don’t want to have these kinds of conversations – a preference doctors should respect, Smith said – this man found the discussion helpful.
For many caregivers, the notion of having these discussions can be fraught with anxiety. In particular, adult children tend to be far less comfortable talking about life’s final chapter than are their parents, according to Dr. James Tulsky, director of the center for palliative care at Duke University. That’s often because the thought of losing a parent raises the prospect of acute loss or helplessness, Tulsky noted.
"Oftentimes, caregivers are coming from a different place than their elderly parents," admitted Smith, who said he tries to resolve potential differences by "talking openly about goals and hopes and fears." In his view, part of that conversation should be openly acknowledging that the end of a parent's life may be closer than a family has previously recognized.
Here's what the data shows and what few caregivers realize: on average, an 85-year-old patient can expect to live an additional six years, depending on his or her health, according to Dr. William Dale, chief of geriatrics and palliative medicine at the University of Chicago Medical Center.
A finer analysis shows that an 85-year-old woman can expect to live about eight more years if she’s in the top 25 percent of her age group, in terms of her overall health. That drops to just over five years if her health is average and about three years if her health is in the bottom 25 percent.
For men, the picture is slightly worse: the healthiest may live an additional six to seven years at age 85, compared to about four years for those of average health and two years for those in poor health.
While Dale carries a card printed with the data in his pocket, he uses it mostly to help hone priorities for a patient’s care. If an 87-year-old woman asks for a colonoscopy, for instance, he may say: "I think that should be down on the list of things we need to worry about now, given that you've made it this far without any problems. Let's think about more pressing medical issues instead."
Dale said, "I'm not so sure you need to say to the patient, 'I think you're going to live only so long and that's why I'm making these recommendations.'"
Other doctors also expressed concerns, and said they were far more interested in discussing end-of-life wishes with elderly adults and their caregivers than reminding patients that their remaining time was limited.
Dr. John B. Anderson, chief medical officer of Duke Primary Care in Durham, N.C., said: "I can't imagine a physician sitting down and telling my 85-year-old mother or father that they have a 25 percent chance of being here six years from now. I don't think that information would be very well received.”
While sympathetic to the UCSF physicians' recommendation, Tulsky of Duke said he was concerned that many doctors aren't trained to talk to patients and their families about these issues. "You don't want to just dump these data; you want these conversations to be handled with sensitivity,” he said.
"Absolutely, it has to be done well or there is the potential for this to backfire," Smith admitted.
In practice, that means conversations might unfold over the course of days or weeks, as patients and their caregivers sort through their feelings and realize the value of addressing the approach of life's end, Smith said. Yet there can be a fine line between addressing necessary issues and unnecessarily alarming elderly patients and their caregivers. Most people don't want their life expectancy "held up to them like a mirror, which they have trouble looking away from," Smith acknowledged.
Judith Graham is a contributing writer for Next Avenue.
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