Helping Geriatricians Choose Wisely

With a rapidly aging U.S. population, physicians caring for older adults are increasingly faced with challenging conversations about what care their patients need – and what care may be unnecessary and could cause harm.

“These are difficult conversations to have with patients,” said Paul Mulhausen, MD, chair of the American Geriatrics Society’s Choosing Wisely® workgroup and adjunct Clinical Professor of Internal Medicine at the University of Iowa Carver College of Medicine. “When patients come to you they bring a lot of expectations. And many times we’re asked to do things through medical interventions that do not offer a lot of value.”

To support physicians in having these conversations, the American Geriatrics Society (AGS) joined the Choosing Wisely campaign and released five “Things Physicians and Patients Should Question” in February 2013. The overwhelming response from its members after the release of the first list led AGS to release a second set of five things this past February.

“We said – what are our members struggling with? What are we seeing in the care environment that concerns us and that we need to do a better job of addressing? And we found that our original inquiry among geriatricians for recommendations for the Choosing Wisely campaign created a list that simply could not be fully captured in the original list of five.”

AGS polled its membership to generate an initial list of potential recommendations, and created a workgroup comprised of members from the Clinical Practice and Models of Care, Ethics, Ethnogeriatrics, and Quality and Performance Measurement committees to further refine the most pressing issues facing providers who care for older adults. The workgroup reviewed the literature and scientific evidence behind each of the topics before recommending inclusion on the final list.

“In the case of one of our recommendations, we collaborated closely with the American Academy of Hospice and Palliative Medicine [AAHPM] to create a coordinated view of the literature that supported our recommendations,” said Dr. Mulhausen.

The shared AGS/AAHPM recommendation, “Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding,” can be particularly difficult for physicians as it often comes at an emotionally trying time for those close to the patient.

“It’s difficult when someone comes to you and says, ‘My loved one isn’t eating – shouldn’t we put in a feeding tube?’ You recognize the pain, and the concern and the good intentions. So you say to them, ‘Maybe that’s not in their best interest’?” said Dr. Mulhausen. “The Choosing Wisely materials help you frame the conversation in a way that it is clear that you’re trying your best to think about what’s best for the patient instead of denying a vulnerable adult access to a medical treatment.”

With participation from more than 60 medical specialty societies, along with 21 grantees and over a dozen consumer groups, the impact of the Choosing Wisely campaign in influencing conversations about unnecessary care is being felt at all levels of the health care system.

“I think it’s moving beyond the national specialty societies and percolating into more local professional organizations as well,” said Dr. Mulhausen. “It’s being incorporated into both continuing education for physicians and other geriatric providers. In terms of helping the health care industry achieve its goal of better quality and lower cost, it’s a very affirming approach.”