Every Patient Is an Individual: Clinicians Balance Individual Factors When Discussing Prognosis with Diverse Frail Elderly Adults

Background: To explore clinician choice of whether to discuss prognosis with their frail older patients. Design: Qualitative interview study. Setting: Primary care clinicians were recruited from nursing homes, community-based clinics, and academic medical centers. Participants: Three geriatric nurse practitioners, nine geriatricians, five general internists, and three family medicine physicians with a mean age of 44 and a mean 12 years in practice. Seventeen clinicians had patient panels with 80% or more community-dwelling outpatients, 13 had patient panels with 50% or more patients aged 85 and older, and 16 had patient panels with 25% or more of patients in a minority group (Asian, African American, Hispanic). Measurements: Clinicians were asked to describe their practice of discussing long-term (<5-year) and short-term (<1-year and 3-month) prognosis. Responses were analyzed qualitatively using constant comparison until thematic saturation was reached. Results: Clinicians reported individualizing the decision to discuss prognosis with their frail older patients based on clinical circumstances. Common reasons for discussing prognosis included patient had a specific condition with a limited prognosis, to give patients time to prepare, to promote informed medical decision-making, and when patients or families prompted the conversation. Common reasons not to discuss included maintaining hope and avoiding anxiety, cognitive impairment or patient unable to understand prognosis, respect for patients' cultural values, and long-term prognosis too uncertain to be useful. Conclusion: Clinicians caring for frail older adults are generally willing to discuss short- but not long-term prognosis. Clinicians balance individual factors when deciding whether to discuss prognosis.