Increasing older patients’ agency in their own health care needs to be balanced against the issues this raises, writes Ben Basger
Older patients often relate their treatment experiences and choices. We may like to express an opinion, but it’s not that easy.
Would it surprise you to know that many medical interventions (treatments, tests and screening) are overused, and this may be compounded by overdiagnosis of many conditions?
Interventions may harm patients—overuse (overtreatment) implying an unfavourable benefit-to-harm ratio because most interventions have some harms which may outweigh the benefits.
Overdiagnosis can harm patients in a number of ways, including the potential for emotional distress caused by the disease label itself, as well as the resultant unnecessary treatment, with associated risks and costs, of latent disease that might never otherwise have caused symptoms or early death 1.
Balancing concerns about the overuse of interventions is underuse. Interventions with strong evidence of overall benefit can improve health outcomes only if patients commence and continue with them.
Reasons for poor adherence to medical recommendations, particularly medication use, include factors such as poor communication about the benefit of interventions.
Patients rely on others to inform them of the likely benefit or harm of various interventions. From this patients may develop their own expectations.
Would it surprise you to know that when patients expectations have been examined, it was found that they rarely had accurate expectations of benefits and harms? For many interventions, they had a tendency to overestimate benefits and underestimate harms1.
It appears that patients have quite an appetite for medical interventions. Many want to have more and resist having less, and this needs to be countered by accurate and balanced information.
While you are digesting this, there is another consideration. Nowadays, respect for autonomy requires that mentally capable older adults be allowed to make treatment decisions.
Person-centred care and shared decision-making models also promote fostering partnerships with individuals and their families to ensure that their values and preferences are incorporated into treatment decision-making.
Yet what if they make poor choices through idiosyncratic thought processes and despite advice?
Ethically, there is a need to promote the individual’s wellbeing at the same time as prevent harm and the inappropriate use of scarce medical resources.
In giving advice to older patients about their treatment choices, the following four aspects could be considered2;
- Medical indication ─ what are the clinical benefits and risks of available options? Will the treatment have any effect on life expectancy?
- Patient preferences ─ does the patient understand the situation? What are their expectations and goals?
- Quality of life ─ will a treatment make it better or worse?
- Contextual features ─ what cultural, religious, financial, familial or relational considerations relate to treatment options?
- Hoffman TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests. A systematic review. JAMA Intern Med 2014;doi:10.1001/jamainternmed.2014.6016.
- Ho A, Spencer M, McGuire M. When frail individuals or their families request nonindicated interventions: usefulness of the four-box ethical approach. J Am Geriatr Soc 2015;63(doi: 10.1111/jgs.13531):1674-78.
Ben Basger is a lecturer and tutor in pharmacy practice, Faculty of Pharmacy, The University of Sydney.