Every Patient Is an Individual: Clinicians Balance Individual Factors When Discussing Prognosis with Diverse Frail Elderly Adults

Authors

  • Julie N. Thai MPH,

    1. Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California
    2. San Francisco Veterans Affairs Medical Center, San Francisco, California
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  • Louise C. Walter MD,

    1. Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California
    2. San Francisco Veterans Affairs Medical Center, San Francisco, California
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  • Catherine Eng MD,

    1. Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California
    2. On Lok Lifeways, San Francisco, California
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  • Alexander K. Smith MD, MS, MPH

    Corresponding author
    1. San Francisco Veterans Affairs Medical Center, San Francisco, California
    • Division of Geriatrics, Department of Medicine, University of California at San Francisco, San Francisco, California
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Address correspondence to Alexander K. Smith, Assistant Professor of Medicine, Division of Geriatrics, Department of Medicine, University of California at San Francisco, 4150 Clement Street (181G), San Francisco, CA, 94121. E-mail: aksmith@ucsf.edu

Abstract

Background

To explore clinician choice of whether to discuss prognosis with their frail older patients.

Design

Qualitative interview study.

Setting

Primary care clinicians were recruited from nursing homes, community-based clinics, and academic medical centers.

Participants

Three geriatric nurse practitioners, nine geriatricians, five general internists, and three family medicine physicians with a mean age of 44 and a mean 12 years in practice. Seventeen clinicians had patient panels with 80% or more community-dwelling outpatients, 13 had patient panels with 50% or more patients aged 85 and older, and 16 had patient panels with 25% or more of patients in a minority group (Asian, African American, Hispanic).

Measurements

Clinicians were asked to describe their practice of discussing long-term (<5-year) and short-term (<1-year and 3-month) prognosis. Responses were analyzed qualitatively using constant comparison until thematic saturation was reached.

Results

Clinicians reported individualizing the decision to discuss prognosis with their frail older patients based on clinical circumstances. Common reasons for discussing prognosis included patient had a specific condition with a limited prognosis, to give patients time to prepare, to promote informed medical decision-making, and when patients or families prompted the conversation. Common reasons not to discuss included maintaining hope and avoiding anxiety, cognitive impairment or patient unable to understand prognosis, respect for patients' cultural values, and long-term prognosis too uncertain to be useful.

Conclusion

Clinicians caring for frail older adults are generally willing to discuss short- but not long-term prognosis. Clinicians balance individual factors when deciding whether to discuss prognosis.

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