Better Care for Some Elderly Patients Means Less Intervention

“Sometimes these interventions don’t provide any benefit and may even increase the person’s suffering,” says Naughton, associate professor of medicine.

In 2004, Naughton established a Geriatric Center of Excellence at UB to strengthen geriatrics training for medical students and physicians.

While that program is changing how physicians approach the elderly, much still needs to be done, he says.

Numerous studies find that older patients with multiple illnesses who stay in an intensive care unit often are less satisfied with the care they receive, as are their families.

Naughton’s own studies, currently being conducted in Western New York, bolster these findings.

“Our preliminary data show that patients over 80 years of age who spend more than four days in the medical—as opposed to surgical—ICU could have as high as a 75 percent chance of dying in the hospital,” he reports.

In addition, published studies find that high-tech care for elderly patients with serious illness is associated with a number of markers of poor care, such as late admission to hospice and transfer from one institution to another within three days of dying.

It can be difficult for physicians and families to decline aggressive, disease-fighting options, says Naughton, even when they severely compromise the patient’s immediate quality of life and, in many circumstances, cannot be expected to provide long-term benefit.

“We have an aging society, access to advanced technology, a very high expectation of what health care can accomplish and a culture that denies that we won’t live forever,” Naughton says.

However, we need to acknowledge that non-beneficial care is wasteful, he adds.

“As physicians, we often feel that it is our responsibility to provide all possible interventions, but really our job is to provide the best care, which in some situations is not going to be the high-tech option.

“Older adults are a diverse group and require individualized treatment. The outcomes expected for one person may not be the same for another.”

It’s time for the health care community to begin a dialogue with the public about what technology can and cannot do for the elderly, Naughton says.

Important steps are already being taken to raise public awareness. Under the Palliative Care Access Act and the Palliative Care Information Act, both passed in 2011, New York State hospital health care providers are required to discuss palliative care with patients whose prognosis is six months or less.

For families of elderly patients facing high-risk procedures, Naughton suggests the following:

• Ask your doctor to discuss life expectancy, in terms of both quantity and quality.
• Ask questions, such as: What are the alternatives to this procedure? What will happen if the surgery isn’t done?
• Always get a second opinion.
• Consider, where possible, a time-limited trial to assess potential gains from interventions, such as dialysis.
• Request a meeting with the hospital’s geriatrics or palliative care specialist as soon as possible.

“The role of the geriatrician is to discuss what the medical technology involves and what are the outcomes,” says Naughton.

“In some cases, once elderly patients and their families fully understand the risks, they may opt not to undergo surgeries that might prolong their lives but seriously compromise their quality of life.”

Older patients should consider what matters most to them about the quality of their life, Naughton says. “I ask my patients: ‘What is the most important thing to you?’”

For some patients, it’s carrying out basic daily tasks, like dressing and bathing, or continuing to live independently.

Families can initiate these conversations with elderly relatives as well, asking them while they’re still healthy what their goals would be if faced with a serious illness.

“Physicians are rarely criticized when they go ahead with a procedure, such as surgery, but they often get criticized when they don’t do the procedure or test,” Naughton says. “We need to better align medical care with the ability to help our patients achieve their goals.”