Your older patients’ care priorities may not be what you think—or what younger patients want
An 82-year-old man with heart failure was presented with a difficult decision: undergo the high-risk surgery his doctors recommended, or die. As Kaiser Health News (KHN) reported, the patient’s daughter felt there was no choice but to go ahead with the surgery.
The man lived for five years afterward. So was the surgery a success? Not according to his family. The patient had a stroke on the operating table and experienced significant cognitive impairment, vascular dementia, and further physical decline until his death. Before the surgery “there was not any broad discussion of what his life might look like if things didn’t go well,” his daughter told KHN. “We couldn’t even imagine what ended up happening.”
It’s a common complaint that doctors miss the mark when it comes to shared decision making with older patients. Why is this, and what can providers do better?
The healthcare system is failing to meet older patients’ needs
It’s important to recognize that older patients often have different priorities than younger ones. For instance, seniors place a higher value on living independently and quality of life. If an operation could save their life but would require significant recovery time in the hospital or a rehab facility, an elderly patient may opt out, preferring to be at home with a spouse (who often relies on their partner for care). A patient in their 30s may consider 20/20 vision a successful outcome of eye surgery. For an elderly patient, however, surgery that preserves their vision and allows them to continue driving may be their idea of success.
Older patients often prioritize living independently and quality of life more than younger patients do, but doctors won’t know unless they ask.
But you won’t know unless you address these issues with your older patients. According to a recent study published in the journal Medical Decision Making, the U.S. healthcare system is failing to meet the needs of a rapidly growing segment of the population—those age 80 and above.
Younger seniors are growing in number as well. People ages 60 and older currently make up 22 percent of the U.S. population—73 million in all, according to Pew Research Center, and it’s estimated that will rise to 26 percent by 2030, as Baby Boomers age.
“Such gaps between the services provided and what really matters to the patient suggest that the process by which we make healthcare decisions with elderly adults is not centered on their individualized needs and preferences, a central part of what determines decision quality,” wrote the journal authors.
Barriers to shared decision making
What are the barriers—perceived or real—that affect the shared decision-making process with older patients?
Many factors can affect shared decision making with senior patients, including a “doctor knows best” assumption, low health literacy, and managing multiple conditions.
Generational biases. One “critical barrier” is doctors’ impression that seniors prefer to leave the decisions to their providers, according to the above-mentioned study.
In fact, there’s some truth to that assumption. We know that different generations make health care decisions differently. Seniors require more frequent and longer patient visits and expect a very high level of service from their doctors. This generation follows their doctors’ recommendations and relies heavily on them for health information.
Studies confirm this, however, the reasons for senior patients’ “doctor knows best” attitude are not clear, noted the researchers. “It may be driven by not feeling knowledgeable enough about health or medicine to make a meaningful contribution to the discussion, rather than a wish to be uninvolved in the decision process.”
Low health literacy. Another frequent barrier to shared decision-making among older patients is health literacy. This is defined by the Patient Protection and Affordable Care Act as the “degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.”
Low health literacy is more common among older adults. According to the U.S. Department of Health and Human Services, adults 65 or older were more likely to have below basic or basic health literacy skills than those under 65. And the share of adults at these lower levels of literacy was greatest for those over 75; more than two-thirds had below basic or basic health literacy.
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“To make matters worse, many healthcare professionals do not speak in terms that are easy for older adults to understand and typically don’t spend significant time with each patient in order to address their questions,” stated the web site MentalHelp.Net.
An increase in multimorbidity. An additional challenge in providing healthcare for older people is the likelihood that you are dealing with not just one condition, but several. Approximately half of older adults have three or more chronic conditions, such as coronary heart disease, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), heart failure, depression, arthritis, and cancer, according to the journal PLOS Medicine. And “multiple conditions complicate shared decision making, as management is not the simple sum of the parts.”
Of particular concern are polypharmacy (the use of multiple prescribed medications by a patient, which increases the risk of adverse drug reactions and interactions) and burden of treatment (high requirements for healthcare visits, refilling prescriptions, diet, self-managing care, etc.).
Five questions to ask senior patients
Doctors can help guide shared decision making with their senior patients by asking five questions, Zara Cooper, M.D., associate professor of surgery at Harvard Medical School, told KHN:
- How does your health affect your day-to-day life?
- When you think about your health, what’s most important to you?
- What are you expecting to gain from this operation?
- What health conditions or treatments worry you most?
- What abilities are so critical to you that you can’t imagine living without them?
Of course, for many older people, the decision-making process will likely also involve family members or caregivers, pointed out PLOS Medicine. So it is essential for doctors to include caregivers in any patient education and communication with elderly patients.
Digital patient education tools—especially high-quality visual materials—can be effective aids in the shared decision-making process because they are accessible to people of any health literacy level and easy to share with caregivers before and after the patient appointment. Modern health care professionals embrace digital patient education as a way to inform, engage, and retain patients.