Benefits with The Local Choice

Talking with Older Patients About Sensitive Subjects (Part 2)

End of Life and Advance Directives

Many older people have thought about the prospect of their own death and are willing to discuss their wishes regarding end-of-life care. You can help ease some of the discomfort simply by being open and willing to talk about dying and related issues or concerns.

You may feel uncomfortable raising the issue, fearing that patients will assume the end is near. In fact, this conversation is best begun well before end-of-life care is appropriate. It may be helpful to talk about a patient's thoughts, values, and desires related to end-of-life care early in your relationship, perhaps when first discussing medical and family history.

Let your patients know that advance care planning is a part of good health care. You can say that, increasingly, people realize the importance of making plans while they are still healthy. You can let them know that these plans can be revised and updated over time or as their health changes.

With a healthy patient, an advance care planning discussion can be relatively brief. Encourage your patients to share the type of care they would choose to have at the end of life, rather than what they don't want. Suggest they discuss end-of-life decisions with family members and other important people in their lives.

Be sure to put a copy of the signed living will, durable power of attorney for health care, or other documents discussing do-not-resuscitate orders (DNROs), organ and tissue donation, dialysis, and blood transfusions in the medical record. Too often, forms are completed but cannot be found when needed. Many organizations now photocopy the forms on neon-colored paper, which is easy to spot in the medical record.

Considering End of Life

If your patient is in the early stages of an illness, it's important to assess whether or not the underlying process is reversible. It's also a good time to discuss how the illness is likely to progress. If your patient is in the early stages of a cognitive problem, it is especially important to discuss advance directives.

Of course, it is not always easy to determine who is close to death; even experienced clinicians find that difficult to predict. If you have already talked with your patient about end-of-life concerns, it still can be hard to know the right time to reintroduce this issue.

Stay alert to cues that the patient may want to talk about this subject again. Some clinicians find it helpful to ask, "Would I be surprised if Mr. Flowers were to die this year?" If the answer is "no," then it makes sense to address end-of-life concerns with the patient and family, including pain and symptom management, home health, and hospice care. You can offer to help patients review their advance directives. Include any updates in the patient's medical record to ensure he or she receives desired care.

For some older people, spirituality takes on new meaning as they age or face serious illness. How a patient views the afterlife can also sometimes help in framing the conversation about serious illness and end-of-life care. Clinicians have found that very direct and simple questions are the best way to broach this subject. You might start, for instance, by asking, "What has helped you to deal with challenges in the past?"

For More Information About End of Life and Advance Directives

Aging with Dignity
1-888-594-7437 (toll-free)
fivewishes@agingwithdignity.org
Link opens in a new windowhttps://www.agingwithdignity.org

Education in Palliative and End-of-life Care (EPEC)
Northwestern University Feinberg School of Medicine
1-312-503-3732
info@epec.net
Link opens in a new windowhttps://www.bioethics.northwestern.edu/programs/epec

National Hospice and Palliative Care Organization (NHPCO)
1-703-837-1500
nhpco_info@nhpco.org
Link opens in a new windowhttps://www.nhpco.org

NHPCO offers educational resources, tools, and webinars for health care professionals on palliative care, including the Journal of Pain and Symptom Management.

NHPCO's CaringInfo
1-800-658-8898 (toll-free)
caringinfo@nhpco.org
Link opens in a new windowhttps://www.nhpco.org/patients-and-caregivers

Financial Barriers

Rising health care costs make it difficult for some people to follow treatment regimens. Your patients may be too embarrassed to mention financial concerns. Studies have shown that many clinicians also are reluctant to bring up costs.

If possible, designate an administrative staff person who has good bedside manner to discuss money and payment questions. This person can also talk with your patient about changes in health insurance.

Long-Term Care

Long-term care includes informal caregiving, assisted living, home health services, adult day care, nursing homes, and community-based programs.

Early in your relationship with an older patient, you can begin to talk about the possibility that he or she may eventually require long-term care of some kind. By raising this topic, you are helping your patient think about what he or she might need in the future and how to plan for those needs. For instance, you might talk about what sort of assistance you think your patient will need, how soon in the future he or she will need the extra help, and where he or she might get this assistance.

Mental Health

Despite many public campaigns to educate people about mental health and illness, there is still a stigma attached to mental health problems. Some older adults may find mental health issues difficult to discuss. Such conversations, however, can be lifesavers. Primary care doctors have a key opportunity to recognize when a patient is depressed or suicidal. Many older patients who commit suicide saw a primary care physician within the previous month. This makes it especially important for you to be alert to the signs and symptoms of depression.

As with other subjects, try a general approach to bringing up mental health concerns. For example, "A lot of us develop sleep problems as we get older, but this can be a sign of depression, which sometimes we can treat." Because older adults may have atypical symptoms, it is important to listen closely to what your patient has to say about trouble sleeping, lack of energy, and general aches and pains. It is easy to dismiss these as "just aging" and leave depression undiagnosed and therefore untreated.

Substance Abuse

Alcohol and drug abuse are major public health problems, even for older adults. Sometimes, people can become dependent on alcohol or other drugs as they confront the challenges of aging, even if they did not have a problem when younger. Because baby boomers have a higher rate of lifetime substance abuse than did their parents, the number of people in this age group needing treatment is likely to grow.

One approach you might try is to mention that some medical conditions can become more complicated as a result of alcohol and other drug use. Another point to make is that alcohol and other drugs can increase the side effects of medication, or even reduce the medicine's effectiveness. From this starting point, you may find it easier to talk about alcohol or other drug use.