Doctors get all sorts of messages from their patients or caregivers. Sometimes they get the “dreaded list,” where an otherwise healthy individual unfolds a laundry list of symptoms, issues and grievances. While the “worried well” represent a small fraction of patients, the bigger concern is with those folks who say nothing at all.
A case in point occurred with my ailing father. I accompanied him to one of his doctor’s appointments and was astounded afterward when he did not divulge any of his symptoms that were troubling him. When I asked him why, he said, “Doctors are paid to figure things out, so let them figure out what’s wrong with me.” As a soon-to-be-graduated physician, I could only scratch my head at his retort. I suppose his thought or belief was that doctors do not need much of a patient history to make a diagnosis. Years later into my career, I became so impressed with colleagues who make a diagnosis almost entirely from a patient’s history. These doctors really know how to ask the right questions, a skill that eludes many modern-day providers whose “go to” communication with the patient seems to be, “let’s get a scan.”
Not to make light of conversations about medical diagnostics, a key point is that these discussions need to be clearly coupled with what matters most to the patient and their functional status. As an example, a health care provider might reflexively order a screening mammogram for an older woman who would not want surgery or chemotherapy should a breast mass be found. One of the rules of thumb we teach our medical students is to not order a bunch of diagnostic tests if the patient does not want to act on abnormal findings.
Knowing patient preferences and health care goals are so important to patient-centered health care. Yet, questions about health care goals are seldom asked or documented in the clinical setting. To address this gap in provider-patient communication, the Geriatric 4M framework for hospitals and clinics puts front and forward the 4M of What Matters Most to older adults. The goal is to firstly ask the older adult What Matters Most, document it, and then share What Matters across the care team. Thereafter, the health care team aligns the care plan with What Matters Most.
So, how do health care providers ask older patients What Matters Most to them?
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When asked directly, one patient responded, “Gee, I don’t know, no one has ever asked that question before.” Reworded, “If there is one part of your health that we could focus on, what would that be so we could help you do (fill in the blank) better? In this instance, a quick response ensued, “well, I want to keep up better with my grandchildren if I could only not get tired so quickly.” With that quick response, the health care provider immediately knows that the symptom of fatigue needs to be medically addressed and it stimulates a bunch of possible health considerations. The point is that by asking "What Matters Most" the health care action plan can be more precisely fine tuned to the needs of the older adult. It’s the other side of the coin for the evolution of Precision Medicine!
Ultimately, questions about What Matters Most need to clarify how medical or surgical treatment could help or perhaps thwart an older adult’s ability to do things they enjoy.
Questions also should focus on a specific time frame and with appreciation of remaining active life expectancy. The term “active life expectancy” is the time when older adults can live in good health, free from disability and chronic illness. This time period often ends by about 2-3 years before “absolute life expectancy” or the definitive end of life. The 2-3 years between active and absolute life expectancy are recognized as a time of increasing disability and frailty. Most people don’t prepare for this transition. Furthermore, many health care providers under-appreciate the assessment and management of this transitional phase. Indeed, studies show that most people vastly overestimate their remaining life expectancy by several years even in face of a terminal chronic condition. Thus, a necessary part of the What Matters conversation needs to fairly evaluate how many years an older adult is expected to live in health and how they should prepare for dwindling health that invariably precedes death.
Under the Age Friendly Health Care framework, the practical application of What Matters Most within a clinical encounter between a health care provider and older adult patient has several options. The Institute for Healthcare Improvement and several other health care websites provide a list of options for health care providers to gather information about What Matters Most to their older adult patients. The simplest and most straightforward way to ask What Matters Most are icebreaker questions such as:
1. “What are your priorities for your health and well-being as you age?”
2. “What are the most important things you want to be able to do or continue doing as you age?
3. “What are your goals for your care and treatment as you grow older?”
4. “What is important to you in terms of your quality of life as you age?”
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5. “What are the things you value most and would like to maintain or improve as you age?”
You do not need to wait for your health care provider to ask these questions. You can jot down your answer and hand the note to your primary care provider. Alternatively, you can go the website for the Stanford (not Sanford, ahem) Letter Project and complete a Letter to Your Doctor: https://med.stanford.edu/letter/letters-in-other-languages.html
The Stanford Letter is a nicely designed template that helps others understand your strategic plan for living now and at the end.
Speaking of the end, not one of my favorite topics, it is very useful to convey to others, including your health care provider, what your wishes might be if you should be in a terminal or near terminal situation. This is where Advance Care Plans (ACP) and Physician Orders for Life Sustaining Treatment (POLST) come into play. Once you have these documents completed and added to your medical record, health care providers can do a better job of honoring your wishes.
As a side comment, research shows that about 85% of people will reverse their end-of-life preferences when confronted with an emergency event. So, the practical application of Advance Care Directives is to be considered as a fluid and ongoing process. Where the process gets gummed up is if and when memory impairment occurs. For this reason, it is important to get your wishes known before there is a loss of judgment and insight.
Hospitals and clinics that strive to be Age Friendly Healthcare Systems have a lot of good options for gathering information on What Matters Most. One option is to send a message out to older adult patients to complete a pre-visit questionnaire. NDSU School of Pharmacy is trialing a pharmacist-provided checklist of What Matters and the other 4Ms. The Stanford Letter template is a great example of pre-visit “homework” for the patient to complete. Alternatively, the Medicare Annual Wellness Exam (it's free, folks) can be the moment when What Matters Most is discussed or revised with your health care team. In my clinical setting, we explored the use of a team-based Annual Wellness Exam where patients see different health professionals for various elements of the exam. We are getting great feedback on this unique clinical approach.
The annual wellness exam sets the stage for future dialogue on What Matters Most to the older patient and allows primary care providers and other team members to align the health care plan to what was revealed in the What Matters Most response. In several certified Age Friendly Health Care systems, the What Matters Most documentation automatically pops up at the top of the patient’s medical note, thus emphasizing its importance to the health care provider’s assessment and action plan for their patient at every point of contact.
Not everyone is prepared to engage in “What Matters” conversations. Some folks feel the weightiness of end-of-life topics that are included in, but not exclusive to, the What Matters dialogue. Others may want to avoid evoking a death spirit, bad luck or connotations about “careful what you wish for.” Clearly, a wide range exists regarding the comfort level, readiness and expectations among older adults about sharing their goals and preferences for their health care. Recognizing these variations, a savvy health care provider utilizes each interaction with older adults as a moment to further advance the What Matters conversation, one step at a time.
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For those highly committed to their health, the What Matters conversation can help sharpen their strategy for living a full and highly functional life. For those familiar with the newly launched Blue Zones project in Grand Forks, the term “la vida” is the phrase used to embrace living with a mission which in turn anchors the What Matters Most dialogue.
In short, the conversation between older adults and health care providers needs to include, “What matters to you?” along with “What is the matter?”
Dr. Donald Jurivich is professor and chairman of Geriatrics at the UND School of Medicine and Health Sciences. He holds the endowed chair established by Eva Gilbertson, M.D., who was the first woman graduate of UND Medical School. Jurivich is the principal investigator for the HRSA funded Dakota Geriatrics Workforce Enhancement Project that supports Age Friendly and Dementia Friendly Health Care. Any opinions expressed in this article are strictly those of the author and do not reflect the opinion of UND or HRSA.
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