Maintain Patience When Caring for Elderly Patients

by G. Richard Holt, MD, MSE, MPH, MABE, D Bioethics •

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?