We hear increasingly about the importance of tackling overtreatment, but less often about how overtreatment plays out in the lives of patients and their families.
In the article below, Associate Professor Magnolia Cardona introduces us to “Walter”, a fictitious character whose story is typical of many older patients, and explains how tackling overtreatment could improve his care.
This article is published as part of the TOO MUCH of a Good Thing series, which is investigating how to reduce overdiagnosis and overtreatment in Australia and globally, and is published as a collaboration between Wiser Healthcare and Croakey.
Magnolia Cardona writes:
“Walter” is a 92 year-old man with an abnormal heart beat that needs daily anticoagulants. He has had progressive and irreversible chronic lung disease for over a decade from being a heavy smoker in his younger age. He hardly recognises his family now due to dementia, and has lost weight without trying.
In the past year he has been hospitalised several times with flare ups of his respiratory condition and bleeding complications from his medicine. Every time he is discharged, he is more frail and less able to return to his normal daily activities at home.
But he and his family may be unaware that he will not recover fully, because dying is not just a point in time but a journey that can take over a year.
Clinicians may not have communicated this trajectory or prognosis openly to Walter for fear of taking his hope away, or because of the relentless sense of duty clinicians have to save lives and ‘do everything possible’.
Importantly, they may not have asked Walter if he considers all these treatments acceptable.
Drawing the line
When a treatment will not make a difference to the patient’s prognosis and is more likely to cause harm and prolong dying or impair the quality of their end of life, this is called overtreatment.
Examples of non-beneficial overtreatment are:
- attempting cardiopulmonary resuscitation (CPR) on older patients who already have a not-for-resuscitation order;
- starting chemotherapy or radiotherapy or dialysis in the last month of life;
- continuing cholesterol-lowering tablets in patients who will not survive long enough to benefit from the long-term effect of those medications;
- performing invasive procedures in ICU on a person who has expressed their desire to die peacefully at home.
In Walter’s case, the repeat hospital admissions will likely be associated with additional medications, tube feeding, invasive ventilation or transfer to intensive care following aspiration pneumonia.
Why would clinicians administer overtreatments?
In non-cancer conditions like Walter’s, clinicians tend to be cautious in conversations about what to do when the inevitable time comes. This is often due to uncertainty about the patient’s time to death and the variable trajectories illnesses may take.
It is not unusual for older patients with cognitive impairment like Walter to have a fall and associated hip fracture, or to experience further confusion or delirium while in hospital due to immobilisation, sleep deprivation, dehydration, deconditioning, or emotional distress.
Decisions that may need to be made at this point include whether to start further psychoactive medications, parenteral nutrition, whether to proceed with surgery, and if he survives, whether to transfer him to an aged care facility after discharge.
In some cases, these treatments are administered contrary to patient preferences because families are anxious and pressure clinicians, or because neither clinicians nor relatives have discussed personal values with the patient before decisions are made.
Clinicians, in their well-meaning sense of duty, tend to adopt a surrogate decision-maker position using transfer of information to patients and relatives, rather than engaging in consultation with them.
They are trained to save lives and cure disease, so sometimes they overtreat because they are not aware that death is not the only outcome that matters to patients.
In cases of cognitive impairment, this may also happen if people like Walter had not previously expressed to their families their views on what is unacceptable treatment or where they prefer to be managed.
Consequences of overtreatment
In the absence of discussions on less aggressive end-of-life management options, patients and families are unaware they can opt to limit or withdraw from treatments. Hence patients present repeatedly to emergency services or are hospitalised for treatments that are sometimes administered too late to be of benefit or are too aggressive, such as intensive care unit (ICU) procedures.
ICU treatments in frail old people often disadvantage patients, who usually die anyway after experiencing days or weeks of poor quality of life, whether during the hospitalisation or in the months following discharge.
This is known to cause family dissatisfaction, long term regret among relatives who consented to the aggressive treatments, and long lasting grief among surrogate decision-makers.
Overtreatment can burden families and make health system budgets unsustainable.
Fortunately, there are several options for society and the health system to reduce overtreatment near the end of life:
1. Evidence-based prognostic tools have become available to supplement clinical judgment. They are checklists with clinical risk factors that indicate level of risk of death, so doctors and nurses can more confidently identify near end of life status.
As these tools are relatively inexpensive and some do not take long to be administered, they could be one of the solutions to prevent or reduce overtreatment. Yet, uptake of these objective prognostic tools is limited. Some clinicians are sceptical about prediction using numbers, others prefer to wait until validation reassures them of near perfect accuracy, others retain the practices they have always had, and others have not read the medical literature to familiarise themselves with these checklists.
2. Disclosing prognosis if there is readiness for the truth. Public attitudes on prognosis later in life are changing, with growing desire for more information on life expectancy and interest in involvement in their treatment decisions near the end. This is an opportunity to fulfil ethical obligations of explaining the anticipated future symptoms and risk of death to the extent that patients and families choose to know.
Contrary to commonly held belief, prognostic disclosure is not always distressing nor detrimental to their emotional wellbeing, and for some people it is liberating. We recommend a gradual approach, depending on the level of patient readiness for prognostic detail, respecting their right to not find out.
Empowering patients and families with the knowledge of a forthcoming death over the ensuing months gives them an opportunity to be part of decisions for their future critical illness, express their views on what they consider unacceptable management, have their affairs in order and say their goodbyes.
3. Public education on advance care planning for future critical illness and on reducing demand for non-beneficial treatments can further assist in containing overtreatment. Involving patients and relatives in informed decision-making can facilitate agreement on management that is not potentially harmful to patients.
Relatives with prior knowledge of the patient’s wishes are less likely to experience guilt about their treatment choices or decisions. Ultimately this can translate into curbing of unnecessary use of healthcare near the end of life and higher satisfaction with healthcare.
4. Reallocating resources into community services. Many older patients dying of progressive chronic illness (natural causes) prefer to be at home for as long as possible, not die in hospital, and have a say on their management to keep their dignity and control of the process.
The health system needs to adapt to cater for services in the community by training community nurses and allied health professionals in supportive and palliative care, to turn these preferences into reality.
Patients like Walter
Clinicians caring for patients like Walter could anticipate his high risk of death using objective clinical parameters and discuss prognosis with his family.
Information on future possible complications and preferences to withhold interventions or withdraw non-beneficial medications in case of future critical episodes could be disclosed to patients and families and documented in an advance care directive.
With the increasing life expectancy and forecast doubling of the world’s proportions of 65+ year-olds by 2050, these conversations on end-of-life treatment preferences need to be held routinely in general practice and aged care facilities before a health crisis arises.
Further suffering for Walter could be prevented by a timely, honest conversation about the inevitable declining trajectory and potential harms of further hospitalisation or aggressive treatments when a natural death approaches.
He could be referred to palliative care assessment earlier; or, if sufficient funding for home nursing and community support existed, his last days could be managed at home, or in another non-acute care facility of his choice.
These resources would ensure he receives comfort care and symptom control that ensure he can achieve a good death.
• Magnolia Cardona is Associate Professor of Health Systems Research and Translation at the Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, and conjoint academic at Gold Coast University Hospital.
The series investigates how to reduce overdiagnosis and overtreatment in Australia and globally. The articles are also available for republication by public interest organisations, upon request.