Many doctors still don't talk to older patients about death

Even though primary care doctors know it’s good for older patients to consider life expectancy in making treatment decisions, many physicians still avoid this discussion, a small study suggests.

When researchers talked about life expectancy with 28 primary care providers, the clinicians described several barriers that keep them from talking about long-term prognosis with their patients including time constraints as well as a lack of confidence in tools commonly used to predict how many years patients have left.

“Discussing life expectancy can be difficult or uncomfortable,” said lead study author Dr. Nancy Schoenborn, a geriatric health researcher at Johns Hopkins University School of Medicine in Baltimore. Older adults of similar age can have very different life expectancies that influence whether they might live long enough to benefit from treating illnesses or taking medicine to prevent disease, Schoenborn and colleagues note in JAMA Internal Medicine.

Almost half of elderly people don’t have an accurate sense of how much longer they’re likely to live previous research has found. This may lead some of them to make poorly informed medical decisions (see Reuters Health article of October 20. 2015, here: reut.rs/23EKnhk).

An accurate sense of life expectancy might, however, lead a cancer patient to skip toxic chemotherapy if they’re not likely to live long enough to benefit from it, or it might encourage someone with diabetes to make lifestyle changes that could improve the last few decades of life.

“Many decisions in primary care require a complex balancing of the potential benefits and potential harms of the decision,” Schoenborn added by email. “Since life expectancy may change that balance, it is one piece of information that can be considered to help tailor medical decisions to each individual patient.”

To get a sense of how primary care providers think about incorporating life expectancy into medical decisions, Schoenborn and colleagues interviewed 26 physicians and two nurse practitioners in a large group practice with multiple sites in rural, suburban and urban settings. Twenty of these practitioners said at least 25 percent of their patients were older adults.

These primary care practitioners reported considering life expectancy, often in the range of five to 10 years, in several clinical scenarios in their care of older patients, but said that they balanced prognosis against various other factors in decision making.

In particular, they were more reluctant to stop preventive care in younger patients with a limited life expectancy, even when these interventions could take many more years to prove beneficial than patients would likely be alive. They did, however, tend to think more about long-term prognosis in planning preventive care for things like cancer screening or diabetes management.

By the time patients reached their 80s and 90s, however, the clinicians said they tended to focus more consistently on addressing advanced directives and goals of care with patients who had a poor long-term prognosis. The study is small, and it’s possible that the views of clinicians in the practice studied might not mirror what happens in other primary care settings.

To the extent clinicians fail to discuss life expectancy due to a lack of confidence in being able to predict long-term prognosis, there are many calculators available online that can help, noted Dr. Alexander Smith of the University of California, San Francisco (UCSF), co-author of an editorial accompanying the study.

One such calculator is ePrognosis (bit.ly/1S6OfAf) from UCSF.

There are two problems with not accounting for prognosis, Smith said by email. “Some older adults with a long prognosis are likely to benefit from tests and treatments that take years to take effect, and if the clinician relies solely on age-based cutoffs these older adults might miss out on beneficial treatments,” Smith said.

“On the other hand, those with a short prognosis who receive tests and treatments (for conditions) that take a long time to develop experience the risks and harms of these treatments up front, with very little chance of benefit down the road,” Smith added.