Maintain Patience When Caring for Elderly Patients

Clinical Scenario

Have you ever heard the expression, “Patience is a virtue”? This statement has never rung truer than for elderly patients you might see in your practice. Consider this example:

Today, you are seeing a new patient, an 82-year-old female who indicated to your medical assistant that she wishes to be referred to as “Miss Lydia.” Miss Lydia is accompanied to her appointment by a caregiver who is not a designated surrogate. The actual designated surrogate is Miss Lydia’s daughter, who lives and works in a nearby town.

During her visit, she tells you that her chief concern is that of worsening imbalance and light-headedness, with an increased risk for falling. (This was also related in the referral that came to you from her primary care physician.)

As you begin your conversation with Miss Lydia and proceed into learning more about her symptoms and associated medical conditions, you begin to understand that Miss Lydia is prone to some mind-wandering and task-irrelevant thoughts. Some of the questions you ask her regarding her symptoms seem easily answered, while other responses are hesitant or, you suspect, may even be inaccurate.

Her caregiver, unfortunately, isn’t much help. She indicates that she is new to the job of caring for Miss Lydia and has only limited historical knowledge of Miss Lydia’s physical and mental condition, including the condition Miss Lydia has visited you for. While Miss Lydia is quite friendly and genuinely pleasant, you understand that this could become a difficult interview, given the complexity of determining a likely set of differential diagnoses. Additionally, your clinic is overbooked today, and your daughter has a soccer game in the late afternoon, which she begged you to attend. Miss Lydia may need more of your time than you can afford to give her.

Discussion

Did that sound like a familiar scenario? As the U.S. population ages and the birth rate declines (by 20% over the past 15 years, by some estimates), otolaryngology–head and neck surgery practices are increasingly treating older patients on a regular basis. Additionally, while the share of elderly persons with dementia or other cognitive dysfunctions appears to be decreasing, the baby boomer population is experiencing a rise in dementia. Indeed, physician experience dealing with patients who have dementia is also increasing—but how will this affect clinical efficiency in busy practices?

It’s well known to otolaryngologists that patient concerns involving balance disorders—vertigo, dizziness, light-headedness, and disequilibrium—require considerable sleuthing efforts to consider potential and probable etiologies for any given patient. Patients with balance disorders often have their first stop with us in the form of a referral from their primary care office to otolaryngology to sort out the complex symptoms. Even with a patient who is a good historian and communicator, the road to diagnosing balance disorders is a time-consuming journey. What is the ethical obligation of an otolaryngologist to provide the necessary time for the encounter, especially when the patient is having some cognitive hesitance in his or her ability to provide clear and concise responses?

When dealing with elderly patients, especially when informed consent is, or will be, required at some point in the encounter, the otolaryngologist needs to deal with the issue of capacity—that is, does the patient have capacity for healthcare decisions? This is usually based on four criteria:

1. An understanding of the elements of the condition(s) and relevant decision;
2. An appreciation of the risks, benefits, and alternatives available;
3. The use of appropriate reasoning in the decision-making process; and
4. The ability to express their choice in clear terms.

While not yet at the point of decision making, Miss Lydia’s probable working diagnosis will hinge in large part on her ability to answer the questions that are pertinent to developing an efficient and effective diagnostic plan. At this point in the history-taking, Miss Lydia’s otolaryngologist is uncertain of the validity of some of her responses, and her description of the onset, frequency, quality, triggers, and length of the symptoms is spotty.

In the furtherance of her care, her otolaryngologist may have several options to consider:

• Should the history-taking be cut short, and a focused physical examination performed, with a plan to contact Miss Lydia’s surrogate relative by phone to determine what further historical information could be gathered, as well as discussing the diagnostic options you may recommend? (At some point, the surrogate does need to be informed, anyway.)
• Should her otolaryngologist gather what information they can get from Miss Lydia and her referring physician, coupled with the focused (i.e., brief) physical examination, and then inform her that an order will be placed for a series of diagnostic tests that will be explained to her by the staff?
• Should her otolaryngologist continue to interact with Miss Lydia, gently probing her memory for any details of importance that can be gleaned, conduct a thorough physical examination pertinent to the potential likely diagnoses, and spend some time discussing the plan moving forward with her and her caregiver?
• Should there be some combination of all of the above?

It’s understandable that dealing with older patients with cognitive function limitations can be time consuming and frustrating. In a busy otolaryngology practice, who has the time to spend more than 10 to 15 minutes with any given patient without making other waiting patients anxious? Besides, you can always have your staff contact the surrogate in your stead while you move on to the next patient. This would be the best approach for efficiency, right?

At one time or another, we have all cared for elderly patients who confabulate and have wandering thoughts as we attempt to learn about their concerns and symptom complexes. Perhaps the caretaker or surrogate has no more information to provide than does the patient. Physicians are as human as the next person, and if we get tied up with one patient, it follows that we must short-change another.

It’s my perspective that patience is a necessary virtue/value for physicians in this time of uncertainty, stress, time constraints, burnout, and cracks in the patient–physician relationship.

There are multiple, time-honored virtues designating the professional qualities of the ethical physician, including compassion, trustworthiness, discernment, moral integrity, humility, conscientiousness, and prudence. It’s my perspective that patience is a necessary virtue/value for physicians in this time of uncertainty, stress, time constraints, burnout, and cracks in the patient–physician relationship. While it’s apparent that efficiency in a medical practice is both a financial and a business requirement, it may play counter to our obligations to our patients to be good listeners, to empathize with their concerns, and to gather sufficient information with which to apply evidence- based medicine. Who has the time to practice patience?

I, like many of my physician colleagues, have also been a patient for a serious health concern. Some of my healthcare encounters with my fellow physicians have demonstrated the importance of patience and time spent listening to the patient. Being a patient can enhance our own approach to caring for others as we begin to understand what’s meaningful to patients when they face challenging health issues. For one thing, the ability to listen is a powerful tool in medicine. Likewise, being present, with patience, particularly with an elderly patient, is pure gold to the relationship. Patience leads to understanding, which in turn leads to the acquisition of more information, and that information is often quite pertinent to the patient’s care.

There are several quite acceptable approaches to the evaluation of Miss Lydia’s concerns and medical issues, leading to the provision of quality care for her. However, if it’s possible, by taking a little extra time to listen to her, to draw out as much information as possible under the circumstances, and not discount all of her recollections as unhelpful, her otolaryngologist can show humanism and compassion as well as care for her effectively. Even for those patients who have dementia, who live in the moment, kindness and understanding is a gift of beneficence from the physician.

I, for one, will most definitely add patience to my list of important physician qualities and virtues.

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Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.