Caroline Helwick

May 22, 2014

ORLANDO, Florida — The goals of the Choosing Wisely campaign, although laudable, can be difficult to achieve, especially when patients and caregivers push for medical interventions not backed by evidence.

Panelists explored communication strategies that can work for clinicians trying to comply with recommendations here at the American Geriatrics Society (AGS) 2014 Annual Scientific Meeting.

The Choosing Wisely campaign was designed by the American Board of Internal Medicine Foundation to help patients choose care that is supported by evidence and avoid tests and procedures they have already received, are harmful, or are not truly necessary. The AGS released its most recent list of Choosing Wisely recommendations in February.

"The goals of the campaign are to promote conversation between physicians and patients; it's not the rationing of care," said Aanand Naik, MD, associate professor of medicine at the Baylor College of Medicine, and chief of education and training care at the Center for Innovations and Quality, Effectiveness, and Safety at the Michael E. DeBakey VA Medical Center in Houston.

Dr. Naik and other speakers advised clinicians to use patient-centered communication that elicits the patient or caregiver's values, and to frame the discussion around those.

"Choosing Wisely decisions are about values," Dr. Nail emphasized. "Values are context-specific and emotion-laden."

It is also helpful to understand how people respond to information, he said.

When making a decision, a person's first response is to make "rapid, intuitive evaluations," which involve a "gut instinct" that is grounded in values, emotions, and experience, he explained. In contrast, the second response involves "data-driven reasoning," which consists of analytical evaluation using facts and knowledge, and occurs more slowly.

He pointed out that of the many values people hold, they retrieve only "emotionally salient" ones during clinical encounters, and these often form the basis of their decisions.

Communication Strategies

Some general communication strategies were provided by Richard Street Jr, PhD, professor of medicine at the Center for Innovations and Quality, Effectiveness, and Safety at the Michael E. DeBakey VA Medical Center in Houston, and professor of communications at Texas A&M University in College Station.

"The key is to provide information in a way the patient understands. Information has no meaning until someone tries to make sense of it. Concerns and preferences are grounded in a reality that is coherent, rational, and meaningful to the patient," he said.

Dr. Street said that it's key to identify the relevant emotions, values, and preferences; establish rapport and partnership; ensure that patients and caregivers understand the disease and treatment information in the context of their values; and achieve mutual understanding and agreement.

The Issue of Percutaneous Feeding Tubes

To demonstrate how these conversations should go, the panelists used the following Choosing Wisely recommendation: Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.

Clinicians who attended the session almost unanimously reported that this is a hot-button issue in their own practices.

Feeding tubes do not prevent aspiration pneumonia, they do not prolong life, and they do not enhance quality of life. But before communicating this information to caregivers, clinicians should talk with the family in a way that builds rapport and elicits the family's value system, speakers explained.

Clinicians should start by describing the patient's current situation, confirm that the family understands the matter, and present the feeding options after exploring more about the family values.

Family members might perceive that enteral feeding prevents starving, offers nutritional benefit, and "gives hope." In contrast, they could feel that by "doing nothing" they are "giving up" on their loved one, and equate "inadequate" feeding with euthanasia, said Dr. Naik.

"The discussion of feeding tubes introduces the emotion of hope, while the discussion of hospice may create fear and anger," he said.

To counter these perceptions, clinicians should note that hand-feeding restores taste and the enjoyment of eating, and it involves human interaction. Importantly, hand-feeding is a way for family members to stay involved with the patient and "be there" in a manner that is less isolating than enteral feeding.

However, he acknowledged, starvation is a "salient" value that taps into the emotions of pain and suffering. This could outweigh the less salient concepts of hand-feeding and isolation in a long-term care facility.

Dr. Naik recommended that clinicians "explore values and emotions first, and use data and evidence to inform the values discussion."

AGS Resources Are Available

The Choosing Wisely campaign was endorsed by Paul Mulhausen, MD, a retired geriatrician who is now chief medical officer for Telligen, a population health management consulting company in Des Moines, Iowa.

"I have had colleagues frame this as things we should not do. I disagree. These are things we should talk about with patients," he told Medscape Medical News.

"We do many things without the evidence that they help patients, yet many of our patients expect certain things," he continued. "Many of the recommendations are about interventions that people take for granted."

Feeding tubes are a good example, he said. "There is almost no evidence these are helpful to patients with advanced dementia. This is a circumstance where it really is about laying out the evidence to a culture that values feeding people," he explained.

Dr. Mulhausen urged clinicians to take advantage of resources offered by the AGS to facilitate these discussions. He said that families need to understand that "this isn't about me telling you not to take care of Mom. It's about discussing the options and saying, 'here are resources to help you understand what I am trying to share'."

"Such resources help clinicians frame conversations in a positive light, in a way that demonstrates the clinician's desire to help the patient, and can result in a shared decision-making process that will facilitate a good outcome," he said.

Dr. Naik, Dr. Street, and Dr. Mulhausen have disclosed no relevant financial relationships.

American Geriatrics Society (AGS) 2014 Annual Scientific Meeting. Presented May 15, 2014.

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