“She was the most incredible woman ever. Very loving. Very kind. But she was also sick,” said Heidi Ann Courtney, a physician assistant at Baystate Medical Center of the grandmother who raised her.
Courtney’s deep connection with her grandmother, who suffered from depression and agoraphobia before passing peacefully from dementia in hospice care, serves as an inspiration for her work.
“At the end they still wanted to do a million things to her. They wanted to give her a feeding tube and all these aggressive things that wouldn’t have made a difference. So that’s when I decided I would do what I could to make a difference. I wanted to do more with less,” she said.
In recognition of her efforts to advance the Choosing Wisely® campaign, particularly in the geriatrics field, Courtney was recently recognized as a Choosing Wisely Champion by the American Geriatrics Society (AGS). Announced earlier this year, the Champions program is an initiative to recognize clinicians who are leading efforts to reduce overuse and waste in medicine. More than a dozen leading medical specialty societies have committed to participate in the program.
“I find it very humbling because it’s just what I do,” she said. “It’s not a job. It’s a calling to take care of our elders. They took care of us, and we pay it forward. That’s part of life.”
Influenced by her grandmother’s experience near the end of her life, Courtney works to reduce overuse of feeding tubes for other patients per the AGS recommendation, “Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.”
“Patients with dementia are very delirious and aren’t able to participate in that discussion. So you’re talking to family members about their loved one, and they don’t want to see them suffer. There’s a human nature that makes us think that if we’re not feeding them, that they’re starving and suffering. Starvation is wanting food but not having access to it, but our frail elders are not wanting of food,” she said. “I try to reassure them that they’re actually not suffering, and that by not putting in a feeding tube we’re aiding them in a peaceful passing. And if they do want a little then we assist them orally as best as possible.”
Courtney also ensures elderly patients don’t receive medications they don’t need, in support of the AGS recommendation, “Don’t prescribe a medication without conducting a drug regimen review.”
She leads an interdisciplinary team that includes pharmacists, nurses and dieticians to conduct chart biopsies. The team looks at why a particular patient came in, what they’re presenting with and what their health history is. With the pharmacist, she looks at each diagnosis and matches it up with current medications – often finding that some patients are taking a specific medication simply because no one ever told them to stop.
“A patient will leave the hospital and go to rehab, but something may happen there and they’ll return to the hospital, and still be on medications that were intended only for temporary use,” Courtney said. “It wasn’t supposed to last months, or even years. But no one readdressed it.”
Courtney also factors in life expectancy and the supporting evidence base when considering which medications can be stopped. For example, some elderly patients shouldn’t be on statins for primary prevention as they likely won’t live long enough to see a benefit, and in fact could be harmed due to adverse effects. This is in line with AMDA’s Choosing Wisely recommendation, “Don’t routinely prescribe lipid-lowering medications in individuals with a limited life expectancy.”
“If you have a frail elder, and you’re looking at all the different co-morbidities she has, and she has a life expectancy of four to five years, why are we keeping her on a medication that’s going to take four or five years to work?” she asked.
Courtney’s work has resulted in more than a thousand drug adjustments for patients, including an effort aimed at delirium prevention that decreased incidence from 20.8 to 15.1 percent in the first year. She was also able to lower the prescription rate for new antipsychotics from 9 to 3.9 percent in the first year of a pilot project. She believes continued education of clinicians, as well as genuine empathy for patients and their families, is key to reducing unnecessary interventions and ultimately improving quality of life.
“Physicians will say to me, ‘I don’t understand, we thought the patient was nearing the end of her life.’ But then we transition her to hospice and take away a lot of unnecessary things. Now she’s sitting up in bed asking for a Big Mac and smiling,” she said.
Members of the American Geriatrics Society submitted nominations for Choosing Wisely Champions beginning in February 2016. The panel of experts responsible for the AGS Choosing Wisely recommendations reviewed each candidate’s application before selecting the Society’s final Champions in advance of the AGS 2016 Annual Scientific Meeting.