- Doctors should broach the subject of life expectancy and end-of-life care, but their patients may not choose to participate in the conversation, according to a recent study published in the Journal of the American Board of Family Medicine.
Holding life expectancy conversations is an important part of treating an older patient, the researchers acknowledged. The conversations help providers understand end-of-life patient wishes, which can then improve patient quality of life as patient health declines.
Additionally, this can improve the grieving process for family caregivers who will benefit from seeing their loved ones’ needs met at the end of the patient’s life.
But research shows that providers often reproach from the subject of life expectancy with their patients.
“Research and clinical-practice guidelines recommend incorporating life expectancy in the range of years to inform decisions such as cancer screening and glycemic goal in diabetes mellitus treatment for older adults,” the researchers said. “How to best communicate life expectancy is not clear and primary care clinicians report discomfort with these discussions.”
A separate 2016 report from the John A. Hartford Foundation, the California Health Care Foundation, and Cambria Health Foundation, found that 99 percent of providers agree that end-of-life and life expectancy conversations are helpful. Medicare has even begun reimbursing for these conversations because they bring value to patient care.
However, only 14 percent of providers have billed Medicare for end-of-life conversations, saying that life expectancy conversations are difficult and they receive little training from their institutions about how to carry these discussions.
According to the JABFM researchers, providers should focus more on whether their patient wants to hold the conversation, not just the timing and the content of the conversations.
Through interviews with 40 patients living in an urban senior assisted living community, the researchers found that life expectancy conversations do not harm the patient-provider relationship.
About 32 percent of patients said they didn’t want to discuss life expectancy at any time during their clinical journey. The same number of patients said they only wanted to discuss life expectancy when they are truly nearing the end of life. The remaining patients said they would be open to these conversations when their life expectancy reaches about one year.
Nearly all of the patients said they would not be put off by a provider bringing up the conversation. While the patient may decline to continue the conversation, she would not be offended by a provider who wanted to discuss end-of-life.
The researchers also asked patient respondents for suggestions for beginning life expectancy conversations.
Most patients said providers could use a major health episode – beginning dialysis, for example – as an impetus for beginning an end-of-life conversation. Others said discussing chronic conditions and how they influence health decline could be a transition.
Some patients stated that involving family members during life expectancy conversations could be useful.
Overall, the patient respondents revealed various preferences for holding life expectancy conversations, showing that there is no single approach providers should use for holding these discussions.
“The heterogeneity among older adults’ preferences for the timing and content of life expectancy discussions highlight the importance of eliciting patient preference regarding whether and when to have a discussion and how information should be presented,” the researchers explained.
But providers should not be afraid to bring up the subject, the researchers and respondents said. Most patients will not be offended by a provider who begins an end-of-life conversation, but the patient may choose not to continue the discussion.
“Offering discussion is an acceptable way for primary care clinicians to open the conversation,” the team concluded. “Suggestions from participants, such as using health decline as a trigger for discussion, can inform future studies to improve the communication around this important topic.”