Five Things Physicians and Patients Should Question in Palliative Care and Geriatrics

The American Academy of Hospice and Palliative Medicine (AAHPM) and the American Geriatrics Society have partnered up the American Board of Internal Medicine (ABIM) Foundation in producing two lists of  “Five Things Physicians and Patients Should Question.”  These lists just published today provide targeted, evidence-based recommendations to help physicians and patients have conversations about making wise choices about their care in order to avoid interventions that provide little to no benefit.

AAHPM’s Choosing Wisely list of 5 Five Things Physicians and Patients Should Question are the following:

1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
2. Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
3. Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.
4. Don’t recommend more than a single fraction of palliative radiation for
   an uncomplicated painful bone metastasis.
5. Don’t use topical lorazepam (Ativan), diphenhydramine (Benadryl),
   haloperidol (Haldol) (“ABH”) gel for nausea.

Interestingly, AGS’s list of Five Things Physicians and Patients Should Question starts off on a very similar note as AAHPM’s list:

1. Don’t recommend percutaneous feeding tubes in patients with
   advanced dementia; instead offer oral assisted feeding.
2. Don’t use antipsychotics as first choice to treat behavioral and psychological symptoms of dementia.
3. Avoid using medications to achieve hemoglobin A1c less than 7.5 in most
   adults age 65 and older; moderate control is generally better. 
4. Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium. 
5. Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. 

I’m a big fan of both lists.  First, I think having both societies give clear recommendations not to recommend percutaneous feeding tubes for individuals with advanced dementia is a bold step in the right direction.

Secondly, there are many things on both lists that I still see used by members of our respective fields.  For instance, ABH and anti-nausea gels are still commonly prescribed in home hospice despite the fact that they aren’t absorbed through the skin.

Lastly, there are things on the list that I think we can focus on from a quality improvement standpoint. As an example, fewer than 10% of US hospices have AICD deactivation policies.   Bringing this information back to our teams and asking simple questions like “do we have an AICD policy?” is one way to move this conversation forward.

by: Eric Widera (@ewidera)