A tool to strengthen the older patient-companion partnership in primary care: results from a pilot study

OBJECTIVES

To determine the acceptability of a pre-consultation checklist for older adults who attend medical visits with an unpaid companion and to evaluate its effects on visit communication.

DESIGN

Randomized controlled pilot study.

SETTING

Academic geriatrics ambulatory clinic.

PARTICIPANTS

Thirty-two individuals aged 65 and older and their unpaid companions.

INTERVENTION

A self-administered checklist was compared with usual care. The checklist was designed to elicit and align patient and companion perspectives regarding health concerns to discuss with the doctor and stimulate discussion about the companion's role in the visit.

MEASUREMENT

PRIMARY OUTCOME

ratio of patient-centered communication, coded from visit audiotapes.

SECONDARY OUTCOMES

checklist acceptability; visit duration; patient-companion verbal activity; patient- and physician-reported perspectives of the visit.

RESULTS

All intervention patients and companions (n = 17) completed the checklist, and all participants (n = 32 dyads) completed the study. Patients and companions stated that the checklist was easy to complete (88%) and useful (91%), and they uniformly (100%) recommended it to other patients. Communication was significantly more patient-centered in intervention group visits (ratio of 1.22 vs 0.71; P = .03). Visit duration (35.0 and 30.6 minutes; P = .34) and percentage of total verbal activity contributed by patients and companions (58.2% and 56.3% of visit statements; P = .50) were comparable in the intervention and control groups, respectively. Physicians were more likely to indicate that intervention companions "helped them provide good care to the patient" (94% vs 60%; P = .02). Intervention patients were more likely to indicate that they "better understood their doctor's advice and explanations" because their companion was present (82% vs 47%; P = .03).

CONCLUSION

A checklist to elicit and align perspectives of older adults and their companions resulted in enhanced patient-centered medical visit communication.

The unknown profession: a geriatrician

The term "plastic surgeon" is oddly uninformative, although it seems likely that most people know what plastic surgeons do. How well can a sample of individuals encountered on the street describe what geriatricians do? To answer this question, we strolled through downtown Baltimore's Inner Harbor, armed with a video camera and picture identification cards to ask the following question: "What is a geriatrician?" Two of us (PA, JY), from the Johns Hopkins Division of Geriatric Medicine and Gerontology, surveyed a convenience sample of people aged 18-80. To further enhance this survey, a video of the interviews was produced (available in online version of article). We entered this exercise having recently joined the ranks of geriatricians-prepared to improve the health and quality of care of our elderly patients. Our naive excitement at entering this noble specialty was trampled by the reality that virtually no one we interviewed knew what a geriatrician was. Answers like, "somebody who works for Ben and Jerry's ice cream" were amusing but at the same time typical and sobering. This simple survey reveals a distressing gap in the public's knowledge of the field of geriatrics and the need for better understanding of its importance to public health and individual health. After all, if people do not know what a geriatrician is, how can they support the growth of geriatrics or seek care from us?

When doctors and daughters disagree: twenty-two days and two blinks of an eye

A cornerstone of American medical ethics is the right to say, "Keep your hands off of me," to decline medical treatment. A central problem is how to decide about individuals who have become incapacitated and can no longer request or refuse potentially life-sustaining treatment. An advance directive is a formal attempt to protect people's right to autonomy when they are no longer autonomous. As such, it assumes that previously expressed wishes are precise and immutable, but many families make decisions together, and individuals may negotiate, compromise, and modify their genuine preferences, especially when novel threats arise, and the stakes are high. The current article describes a case in which two daughters overruled a patient's explicit preference to refuse life-sustaining treatment, leading to burdensome illness before death. In the end, the mother seemed to understand her children's needs and seemed willing, at least in retrospect, to have met those needs. After the death of this individual, we continued to talk with the daughters and videotaped an interview in which they shared their perspectives on the case. The daughters consented to be videotaped and to share the video with the medical community (available in online version of article). Their forceful devotion to their mother and their search in retrospect for what could have been done differently has completely changed our understanding of events. We believe that the daughters' behavior is not the indefensible breach of respect for person that it seemed to be. Their mother's true wishes might well have included a desire to help her children during her own dying. Family members' preferences are likely to be important considerations for many people, although the possibility of coercion has to be acknowledged as well. Accommodating this level of decision-making complexity is highly problematic for our understanding of advance directives.