Clinical Geriatrics

Palliative care aims to improve the quality of life for patients and families living with serious illnesses. In addition to expert pain and symptom management, palliative care requires advanced communication skills.^1,2 The first part of this series (Clinical Geriatrics 2007;15[1]:25-32) discussed pain and symptom management for the geriatric patient. This article will focus on the essential skills for effective communication.

The Problem of Poor Communication
Good communication skills are essential when caring for ill patients, yet several studies have shown that patients are not satisfied with their experiences communicating with physicians.^3,4 As death approaches, patients are concerned that physicians are not listening to them, and they fear a death with unnecessary suffering.^5,6, The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) trial was a large multicenter study of more than 9000 patients with serious illnesses. In this study, only 47% of physicians knew their patients’ preferences for resuscitation.⁴

The dissatisfaction of patients and the disconnect with physicians may stem from a lack of training in communication methods in both medical school and residency.⁷ Other factors that make it difficult for physicians to communicate with patients include time restraints, discomfort with discussions about death, and a fragmented medical system.⁶

Several studies have shown that communication style is very important to the satisfaction of the encounter.^8-10 Open-ended questions, emotional support, and concern for psychosocial distress lead to higher levels of satisfaction.

Advance Care Planning
Communication and discussion regarding treatment preferences should start before a patient is seriously ill.

Consider the case of Mr. TH, who is 77 years old and has diabetes and hypertension. His medical conditions are well controlled on multiple medications, and he comes to your geriatric practice every 3 months for check-ups. This is the ideal time to discuss advance directives with the patient because his health is stable, and you are a physician he knows and trusts.

Advance directives are important because they preserve the central tenet in the bioethics of autonomy: A competent patient can decide which medical treatments are to be done.¹¹ Thus, if a patient is unable to make decisions for himself, the physicians and surrogates will be able to make decisions based on the patient’s prior wishes.

Written advance directives can be categorized into instructional and proxy. Instructional advance directives, such as living wills and do-not-resuscitate orders, specify the types of interventions that a patient does or does not want in particular circumstances. Proxy directives, such as healthcare proxy and a durable power of attorney for health, authorize another person to make medical decisions if the patient is unable.¹² Although these documents can designate wishes for any type of medical treatment, they are most often used to specify wishes regarding life-sustaining treatments and care at the end of life.

Every state has a statute that recognizes a patient’s right to prepare advance directives; however, the law regarding advance directives differs on a state level. For example, in New York State, a healthcare proxy can make decisions about resuscitation, but needs reasonable evidence of the patient’s wishes to withhold artificial nutrition and hydration. In other states, the healthcare proxy may have more power to withhold these measures.

An initial approach to advance care planning can focus on a patient’s understanding of medical care and his/her definition of a good quality of life.^13,14 The physician and patient should then identify situations in which a patient would not want his/her life prolonged.