Conversations every physician should have about aging

Age-friendly care means creating the space to discuss patients’ goals around aging with dignity, independence, and choice. Sharing these principles of age-friendly care has grown even more critical as the number of Americans who are 65 and older is expected to double to more than 98 million by 2060, or nearly 1 out of 4 people in the U.S. This means ensuring all future and current physicians — not just geriatricians — are trained to deliver age-friendly care and to work with patients to identify what matters to them when it comes to care goals and treatment plans.

In this PermanenteDocs Chat Short, Tyler Darnell, MD, an emergency medicine physician and medical director of Dignified Journeys at Northwest Permanente, discusses why it’s so important for patients, their families, and physicians to talk about end-of-life planning, advance care directives, and more. He offers tips and advice designed for physicians of all practice areas on how to have these vital conversations around issues of patient wishes in their treatment journeys.

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Dr. Tyler Darnell: We can’t prevent aging. We can’t stop that from happening, but we can try to prevent some of those illnesses that develop as we age through our screening processes and through good preventative care.

Why is it so important to talk about healthy aging early?

TD: As Permanente physicians, we actually, we make this promise to our patients that we’re going to talk to them about healthy aging, that we’re going to talk to them about their goals and their wishes. And I think that it’s nice to remind them that we’re here for them for that. And we need to encourage and ask our physicians to honor that promise we make to them and really talk to their patients about these things.

One thing I think that physicians and patients need to recognize is the importance of talking about healthy aging and really what that means. The social aspects, the psychological and emotional aspects, but also the physical aspects of what goes along with healthy aging.

How do you start the conversation with family members in the emergency department?

TD: When grandma or grandpa come to the emergency department, oftentimes they’re not coming alone. There’s a neighbor, there’s a cousin, there may be someone from church, there may be a sister calling in from another state and it’s because they’re all worried. And so when I get to have this conversation and the patient expresses their wishes around their family, I get to look at that family and those loved ones and I get to say, “Okay, we heard what they want. ” And what a blessing that is because I’ve seen so many times where families have this burden of making the decision because they never had this conversation with their loved one, with my patient.

And so to be able to provide a space for this in the context of medicine, the context of why the patient is presenting to the emergency department, that feels really, really special to me.

Where can people begin the conversation before speaking with their doctor?

TD: Oh, there are so many resources online. In fact, you can go to kp.org/lifecareplanning and that’s going to tell you about how CPR works. That’s going to tell you what questions to ask or how to start the conversation with your physician or how to start the conversation with your family. There’s an advance directive on there that you can fill out. So this is a great resource, even specifically talking about healthy aging. So I try to direct everyone there. Other than that, I mean, advance care planning and life care planning, there are games to talk about this in communities to try to get more comfort around the conversation, to try to bring in family members with the patient to start talking about these things. But yeah, I think kp.org/lifecareplanning is a great resource for all of our members. And these conversations, they’re not a one and done.

The documentation’s not a one and done. This is a living part of the patient’s chart because the patient’s disease may progres or something family related or social related may happen. They’ve assigned a spouse as their healthcare agent and their spouse dies. And so we need to make that commitment to have these conversations annually with the patient to check in and see if anything has changed around their wishes. And part of that is updating advance directives or updating a POLST form and just making sure that anyone on the care team has access to what the patient’s wanting during this time of their life. And then again, just continue that conversation as things change for the patient.

How well are physicians being prepared to deliver age-friendly care?

TD: When I’m lecturing, one of the questions I always ask is, “Have you had any formal training outside of this lecture?” And I’m hearing yes more and more. So they’re being trained on what the context of the conversation should be like, which patient populations need to be targeted. I think where we need to focus is on the finesse of the conversation. How much do we push? How much do we pull? Is the door open? Is the door closed? How do we get our foot in there? And really that just comes along with practice. We practice medicine. We have to practice these conversations as part of that. I mean, we see it on these medical shows, right on all these 911 shows where someone goes into cardiac arrest and we do all these aggressive measures. And then after the commercial break, they’re awake and doing fine and it’s just like that.

But that’s not the reality. And so I want physicians, I want providers that are having these conversations. I want them to feel empowered to make recommendations on goals of care for patients. You have listened to what the patient wants and you have this medical context where you can help guide them. And I think that’s really important. I just want physicians to really remember that their patients trust them and they’re asking for guidance here.

Do you have any advice for fellow physicians?

TD: I think that’s something that’s important is to not get discouraged when you’re having these conversations. They can be tough. Patients may not want to have them or you may say just the wrong thing that turns them away. But you have to have those conversations so you can tell the patient how you can help them with their goals, how you can help them through healthy aging. And so just keep trying, keep reaching out, go to your resources, practice these conversations because they will be some of the most meaningful conversations you have with your patients. And they’re so important because that’s how we get to know our patient. That’s how we get to help guide them and help them age healthily and help honor their goals of care towards end of life. I mean, we all have a role in this. It’s like you’ve got a puzzle of the patient and it’s their goals of care.

And so there’s a piece from the cardiologist, there’s a piece from nephrologist, there’s a piece from me in the emergency department. And then we put that together and we finally get this full picture of what the patient’s goals of care are. And then the patient knows that we have that. The care team can see that. The patient’s family knows that we’ve listened and then they can see what the patient wants. And so we’re able to see this full picture and for our patient, we’re able to honor what their wishes are as a disease progress or towards end of life.