An article by National Institutes of Health Clinical Bioethics director Ezekiel Emanuel, MD, PhD, in The Atlantic about his preference not to prolong his life after age 75 hit a nerve with many physicians. The personal preferences of a public policymaker are dangerous, some have argued.
We reached out to physicians by email to ask:
Should we change goals of care after a certain age and, if so, how?
The participants this week:
Louise Aronson, MD, MFA, Director at Northern California Geriatrics Education Center and Director of Medical Humanities at University of California San Francisco
Eduardo Bruera, MD, Department Chair of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center
Jonathan M. Flacker, MD, Chief of Geriatrics and Gerontology, Emory University School of Medicine
Kyle P. Edmonds, MD, palliative medicine specialist, University of California San Diego Health Sciences
Jordan Grumet, MD, internist, Highland Park, Ill.
Emily Lu, MD, PGY-1 in Family and Community Medicine, University of California San Francisco/San Francisco General Hospital
Christian Sinclair, MD, hospice and palliative care specialist, Kansas City, Mo., and editor of Pallimed: A Hospice and Palliative Medicine Blog
Alexander K. Smith, MD, MPH, geriatrician and palliative care specialist, University of California San Francisco and San Francisco VA Medical Center, and co-founder of GeriPal: A Geriatrics and Palliative Care Blog
Michael Steinman, MD, geriatrician, University of California San Francisco and San Francisco VA Medical Center
Age Is Irrelevant
Jonathan M. Flacker, MD: "Functionally speaking ... when you've seen one 75-year-old, all you've seen is one 75-year-old. Goals of care need to be determined as person appropriate, not age appropriate."
Louise Aronson, MD: "I suspect the challenge of that question -- and of Dr. Emanuel's at first glance inflammatory but also thoughtful and thought-provoking article in The Atlantic -- is the notion that there is a specific and universal age at which goals should change."
Christian Sinclair, MD: "What surprises me most is to see Dr. Emanuel ignore the well-known essay by biologist Stephen Jay Gould, when he was diagnosed with mesothelioma in 1985, 'The Median Isn't the Message.' In regards to the relationship of function/creativity to increasing age, one should be very cautious to base important personal decisions merely on population-based statistics."
Alexander K. Smith, MD: "Dr. Emanuel was right on about the increase in disability and dementia among people who live to advancing age. Here is what he got wrong. The right people to ask about quality of life are not younger, healthy people (like Dr. Emanuel), forecasting what it would be like to be 85 years old and disabled. The right people to ask are 85-year-olds living with disability. In a study we conducted of 65 disabled older adults in a supportive care program, a majority rate their quality of life as good or better."
Emily Lu, MD: "I think practically speaking I (and likely other doctors) start revisiting goals of care before patients are critically ill past a certain age. But the question is kind of crazy -- it's not a specific number, but because of any number of things that [are] happening in your (or your patient's) life at the time."
Jordan Grumet, MD: "We have spent the last few decades building a patient-centric, personalized healthcare system. A 75-year-old marathon runner in perfect health may have different needs and wants than a 75-year-old with metastatic colon cancer. In its best version, our current medical system can accommodate both."
Kyle P. Edmonds, MD: "Absolutely not. Goals of care are personal and related to a patient's life story, values, family system, and hopes. Therefore, goals must be 'patient-centered and family-oriented' as the Institute of Medicine put it in their new 'Dying in America' report last week. Clearly, however, our system is failing at caring for the seriously ill in a patient-centered way."
Changing Goals
Michael Steinman, MD: "It is difficult to prejudge how one will feel living with chronic illness, functional impairment, and the physical and cognitive slowing that often comes with advancing age. Some people who had thought such a life would not be worth living discover that they remain happy and engaged despite these limitations."
Edward Bruera, MD: "Goals of care (and goals of life) vary considerably from person to person and over time. Most healthy adults find limited meaning and quality to a life with advanced cancer, not being able to work, with limited mobility and needing pain medication. However, the vast majority of advanced cancer patients find meaning and quality to their daily life (and they were part of the healthy cohort only a few years back). Adaptation to change and losses related to disease and age are quite common."
Aronson: "The reason goals of care are so important in guiding decision-making and care is that they are individual and depend on a person's values, life circumstances, and health. Age enters into the equation insofar as it impacts those more fundamental determinants. Choosing a 'certain age' may be pragmatic at a systems or population level, but it lets clinicians off the hook too easily and does a disservice to patients. Should/will most 85-year-olds have different goals than most 55-year-olds? Yes, but where and when they make that change will/should vary widely."
Flacker: "Goals of care change throughout life and reflect personal abilities, values, overall health, and cultural expectations just to name a few factors ... A major problem we have at present is that goals of care discussions are often intervention-specific ('If you stop breathing should you be put you on a machine to breathe for you?'), or even worse, not discussed at all. Only when our societal norms change so that all people at every age understand the importance of thinking through and expressing your goals of care will an individualized, nuanced, decision-making approach be possible."
How to Personalize Care
Steinman: "Advance care planning works best as a process for thinking through goals of care, including revisiting those goals over time, rather than a one-time decision about which types of care to accept or reject."
Bruera: "Frequent review of goals based on how the patient is doing now is more useful than asking patients to establish advanced goals based on how they might (or not) feel sometime in the future."
Smith: "A good quality of life is possible, with support. I suspect [Emanuel] would agree with me that we spend far too much on trying to make the 75-year-old live to 85, and not enough to support the quality of life for 85-year-olds who are already living with disability and dementia."
Aronson: "A better solution is to train, reimburse, and reward clinicians to engage in these critical conversations."
Sinclair: "A challenging task of a physician is to help personalize shared decision-making with a patient based on the knowledge of the available data. So many times, the person in front of us is not represented in the data set studied in the research. In addition, the comparison to worth and external glory and achievements ignores who we are worth most to -- our family and friends. [Emanuel] should listen to the protests of his family who deem him crazy for his opinion about his value."
Lu: "As doctors, we should be there to help guide people through that conversation and, as a society, we should be more supportive of people having that conversation."
Edmonds: "To achieve better care for those patients, we must improve communication skills training for all physicians and other healthcare workers so that they can best elicit and understand patient goals. At the same time, physicians need to own their expertise and be more proactive in sharing their opinion when certain medical interventions will no longer meet a patient's goals of care. For complex cases, the health system must support more specialist-level palliative care professionals to assist with communication and decision-making in the seriously ill. Finally, as a society, there must be less emphasis on checkbox-like advance directives and more guidance given to patients and families on how to talk about their goals though projects like The Conversation Project."
You may also be interested in these recent Friday Feedbacks:
Is Today's Standard Care Tomorrow's Horror?
Zero-Tolerance Employment Smoking Bans?
MD Celebrities in the Land of Oz
Friday Feedback is a feature that presents a sampling of opinions solicited by MedPage Today in response to a healthcare issue, clinical controversy, or new finding reported that week. We always welcome new, thoughtful voices. If you'd like to participate in a Friday Feedback, or suggest a topic, drop us a line or two.