By Karen Born and Paddy Quail
Clinicians working in home and long-term are at the front lines of a tide of change in health care. Seniors aged 85 and above are the fastest growing age group in Canada, and our hospital-centric health care system is not set up to meet the complex and ongoing health needs of seniors, and especially elderly seniors. Approximately 75-80 per cent of Canadian seniors have one or more chronic condition.
We are faced daily with the challenge of providing high-quality, evidence-based and patient-centred healthcare. This can include demands from our colleagues, caregivers and patients for more – more medications, more testing, more procedures to try to improve our patients’ health. But sometimes in medicine, as in life, more is not always better.
A recently-released report from the Canadian Institute of Health Information found that up to 30 per cent of all healthcare provided in Canada offers no clinical value to patients. Overuse and unnecessary care harms our patients, and is wasteful of health care system resources.
For example, the report notes that one in 10 Canadian seniors are chronic users of benzodiazepines. Benzodiazepines are a powerful class of drugs intended for short-term use to manage insomnia or anxiety, but long-term use impairs thinking and mobility, leading to increased accidents and falls.
While we prescribe drugs such as benzodiazepines to try to solve a medical problem, they can cause more problems and harm than good to our patients.
A clinician-led campaign, Choosing Wisely Canada, is raising awareness among patients and the public about the harms of unnecessary care and overuse. National clinician specialty societies have joined the campaign by releasing lists of recommendations of overused tests, treatments and procedures that are not supported by evidence.
The campaign was launched in 2014 in Canada, and earlier this year the Long Term Care Medical Directors Association of Canada released their list of ‘Six Things Physicians and Patients Should Question’. These recommendations are added to the over 230 recommendations released in Canada to date. Choosing Wisely is an international campaign, with over 20 countries worldwide having local campaigns and more are joining.
The Long Term Care Medical Directors Association of Canada struck a small committee, which included a patient representative, and received feedback and approval of the list from association members and board.
The list of recommendations highlights things that clinicians in long-term care and community can do to ensure that patients are receiving high quality care, and avoiding overuse.
Recommendation 1. Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.
This recommendation is based on research that many hospitalizations for seniors are avoidable and can harm more than heal. Hazards of hospitalization for frail elderly patients include delirium, hospital-acquired infections, lack of sleep and rapid deconditioning from being bedridden. If medical needs can be met in their care home, this is the best place for them to be. It is important for clinicians to respect patient and family choices, but also to have informed conversations with patients and caregivers about their goals, and the potential harms of hospitalization.
Recommendation 2. Don’t use antipsychotics as a first choice to treat behavioral and psychological symptoms of dementia.
Behavioral and psychological symptoms of dementia often signs of an underlying problem for elderly patients. Rather than prescribing powerful medications to address the behaviors associated with dementia, treating the underlying cause can make these medications mostly unnecessary. Long-term use of antipsychotics can cause significant harm to patients.
Recommendation 3. Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).
About one half of seniors residing in a nursing home will have bacteria in their urine. This is called colonization. But the presence of bacteria should not automatically mean they should take antibiotics. Antibiotics for patients who have no symptoms of a UTI increases risks of antibiotic associated diarrhea and C.difficile infections and contributes to the increases in antibiotic resistant bacteria which pose a significant harm to our current and future patients.
Recommendation 4. Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat.
Tube feeding in elderly patients has been shown to reduce rather than improve quality of life for elderly patients with advanced dementia. Tube feeding towards the end of life is associated with a host of harms, including risks of aspiration and aspiration pneumonia. While assisted eating can be time consuming and more difficult, it is a safer way to feed patients than tube feeding.
Recommendation 5. Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient.
The older Canadians are, the more medications they take. For seniors in long-term care facilities, the numbers continue to climb. But often multiple medications offer more harm than benefit as they can reduce quality of life and have harmful interactions. Before prescribing a medication to meet lab test targets that apply to adults living in the community, consider potential harms to the function, mobility and mortality of frail elderly seniors.
Recommendation 6. Don’t order screening or routine chronic disease testing just because a blood draw is being done.
Routine tests can cause more harm than good. If there is no treatment plan to enhance quality of life, routine tests in frail elderly patients are clinically useless. Especially as patients near the end of life, their care goals, quality of life and comfort are of paramount importance.
The six items on this list reflect an overall message to clinicians who are dedicated to improving quality for elderly patients receiving care the community and long-term care. As we continue to care for patients who have complex care needs, it is important to have conversations about the benefits, as well as harms of medical tests, treatments and interventions.
Patients and caregivers do appreciate that more is not always better. Especially when clinicians take the time to have a conversation about expectations, hopes and fears during this time in their lives.
Having conversations with patients and using the recommendations from the Choosing Wisely Canada list for long-term care can help to guide expectations and ensure that quality of life, comfort, safety and dignity are prioritized.
Choosing Wisely Canada has developed a list of 4 Questions for patients and caregivers to help get the conversation started.
- Do I really need this test, treatment or procedure?
- What are the downsides?
- Are there simpler, safer options?
- What happens if I do nothing?
Long-term care physicians and medical directors are having the conversation with our colleagues and with patients about how more is not always better. We encourage you to join the conversation and help to improve quality and reduce harm for your patients.
Karen Born, PhD, is Knowledge Translation Lead, Choosing Wisely Canada, and Assistant Professor, Institute of Health Policy, Management & Evaluation. Paddy Quail, MD is President of the Long-Term Care Medical Directors Association of Canada, Medical Lead Supportive Living Alberta Health Services Calgary Zone and Medical Director Intercare Corporate Group Inc.