Older adults are getting too much medical treatment.
No, I am not suggesting we ration treatment for seniors or empower the mythical death panels. Rather, the health system should replace aggressive but ultimately useless medical interventions with more care.
This means rethinking the way we care for older adults with chronic disease. We should organize care around the goal of improving their quality of life rather than on aggressively treating their specific medical conditions. Rather than doing that third scan on the same body part, we could better spend our dollars on home delivered meals or an adult day program for an otherwise homebound senior. Every decision should be based on the answers to two simple questions: Is it what the patient wants? Will it improve her quality of life?
The idea isn’t new, of course. It has been floating around the edges of medicine for years. More hospitals are developing palliative care programs. People at the end of life are increasingly relying on hospice, though still for a too-short period of time. And many are taking more control of their end-of-life care though advanced directives, do-not-hospitalize orders, and right-to-die laws.
But these initiatives are either modest or focused only on people at the very end of life. Many completely miss those who will live for years with chronic conditions. As many 12 million Americans need some level of personal assistance to help with their daily activities. And recent research by my Urban Institute colleague Melissa Favreault finds that 6 million people over 65 will live an average of two years with a very high level of need for assistance, and one in seven older adults will live five years or more needing significant help. But how will they get that support?
Slowly, the medical mainstream is starting to think about this part of the care equation. Even as many people get too much medical treatment, many receive too little assistance with those daily activities that can improve their lives.
A few weeks ago I was asked to present to the Institute of Medicine’s Board on Health Care Services. I don’t know if IOM will adopt this issue as a priority, but the fact that it is even thinking about the overmedicalization of care for older adults is a great step forward.
There is surprisingly little research about the attitudes of American doctors towards the elderly (though there is much more on this topic in Europe). But physicians tell me their colleagues tend to gravitate to the extremes. On one hand, some physicians write off older patients. This is the attitude that leads them to say something like: “Of course it hurts. You’re 85. What do you expect?”
On the other, there are those doctors who can’t bring themselves to stop aggressive treatment when it no longer helps, or may even harm, a patient’s quality of life. Some physicians can’t do this even after a patient has requested an end to over-the-top treatment.
One problem is common to both kinds of docs: Their inability to guide patients to the personal assistance and social supports that could do them the most good. Many physicians don’t even know these services exist, much less have the interest or time to lead their patients to them. Others can’t even imagine that care beyond their specialty is in any way useful.
It will not be easy to turn this ship. It will take changes in culture and in the way Medicare pays.
Patients must have access to the information they need to understand that more treatment is not necessarily better care. Some hospitals do this when they show videos of what it is like to be on a ventilator before asking whether a patient wants to use that device.
For their part, doctors must learn that more aggressive treatment is not always best for their patients. Better data about life expectancy and quality of life in palliative care would help.
Better communication among physicians, patients, and families is essential. Docs need to explicitly ask older patients what they want for treatment. If they must choose between quality of life and prolonged life, which do they prefer? And if patients ask where they can get social supports, docs must be prepared to respond, even if the answer is to send them to a trusted social worker or other expert.
And the payment system has to adjust. If Medicare is going to pay doctors to do more procedures, no one should be surprised to see doctors do more procedures. That too is changing, though only in fits-and-starts. And we need to find resources to pay for those non-medical services that Medicare does not pay for. So far, that’s barely changing at all.
IOM’s interest in this topic is enormously important. It could help signal a fundamental shift in the way physicians think about their older patients (to say nothing of their younger ones). In an era of hyper-specialization, it is not easy to get physicians to care for people rather than treat diseases. But it is not impossible.