The Wait 

The Wait

All day, every day, we wait for something or someone. Currently, we are waiting for the COVID-19 pandemic to end, for immunizations to bring herd immunity, for the curve to flatten, for international borders to open, for mask wearing to end. These are “big asks” and we have been waiting 16 months.

Sarah, an 88-year-old nursing home resident was waiting also. She was waiting to discuss the possibility of knee replacement surgery with her doctor. Her family thought she was too old and would not do well, but Sarah thought they were wrong. She knew the decision could change the course of her life and wanted to hear her doctor’s opinion.

The Conversation

We often rely on technology to confirm a diagnosis; however, our communication with a patient is our single, most valuable diagnostic tool. Talking to our patients and listening to their answers helps us focus on a path to diagnosis and management. This helps build trust in our clinician-patient relationship. Our words matter and since we have the information they need, and want to hear, we can appreciate their desire to meet with us. Our time constraints may make it seem like a “big-ask,” but it brings great value to the patient and fulfills a responsibility we have to them.

The Content

If we are able to discuss risk from the perspective of frailty, we have an objective, mathematical basis to frame the conversation. The need to communicate honestly and forthrightly with the patients and their families is greater now, because of COVID-19. A realistic description of Sarah’s health, frailty level, and the risks associated with these set the stage for informed decision-making. When patients and families understand the impact of frailty on decisions and know about rehabilitation and recovery potential after, for example, knee surgery, discussions about goals and priorities can be more engaging and appropriate. 

Sarah and her family have different priorities, and both might see things differently after the conversation with the physician. To make sure everyone hears and understands each and that decision-making is truly patient-centered, consider these 4 steps:

  1. Reiterate goals and priorities. What is their outcome of importance?
  2. Restate available options. We can manage conservatively or follow Plan #1 or Plan #2.
  3. Remind the patient and family of both positive and negative outcomes for each option.
  4. Reinforce decisions made. “These are the next steps we have agreed on today.”

The Consequences

If we communicate sensitively and in a non-judgmental, empathetic, collaborative way, it will help patients and families have or be open to realistic goals and expectations; and they are less likely to be surprised by predictably unfavorable outcomes. Communicating realistically sets the stage for acceptance rather than anger. 

Sarah’s wait was worth it. Her physician explained the positive outcomes likely to benefit Sarah if the knee replacement was done. Since she was only mildly frail, it would be possible for her to participate in rehabilitation after surgery and likely regain function and reduce pain. These were her outcomes of importance, and the family agreed. 

Sarah’s surgery was successful and now she eagerly waits for physical therapy every day. Still waiting but now increased function and reduced pain are her goals. 

Patient Pattern has tools to enable you to frame your conversations with the objective measurement of frailty and set the stage for true evidence-based, person-centered decision-making. Contact us for more information.