Recent research gives insight into how nurses and other clinicians should approach the conversation with older adults about professional recommendations to discontinue routine screening tests.
The communications study, which focused only on cancer screening, found that older adults were generally open to recommendations to stop screening, but preferred that life expectancy not be brought into the discussion. As an accompanying editorial put it: “It may be that it turns what would have previously been a discussion about maintaining health… into an unexpected discussion about the end of life…. Such prognostic conversations are difficult even when patients are aware that they have a life-threatening disease such as cancer, but may be a shock in the primary care setting at a routine visit.”
Katherine Abraham Evans, president of the Gerontological Advanced Practice Nurses Association, who was not involved with the study, commented that understanding a patient's goals of care is intrinsic to providing patient-centered care no matter the setting. “As older adults age and develop chronic diseases, some screening tests are no longer appropriate. It is critical that nurses understand when testing is no longer indicated and know how to communicate this to patients,” she told AJN. “These conversations must be approached with proper technique. Nurses should explore their comfort in engaging in critical conversations, and if necessary, seek training before discussing treatment preferences.”
Many medical organizations have recommendations for routine screening in individuals over age 65. The Choosing Wisely initiative of the American Board of Internal Medicine Foundation, in partnership with Consumer Reports, has a compilation of screening guidelines here: http://bit.ly/2tFUlG7.
For example, the American Cancer Society advises that routine mammography should continue every two years after age 55, as long as a woman is in good health and expected to live at least 10 more years. For cervical cancer screening, women older than 65 years who have had regular testing in the past 10 years with normal results should not be tested, and once testing is stopped, it should not be restarted.
The study's authors suggest that there may be better phrasing to use in these conversations than “life expectancy”—for example, saying instead “This test would not help you live longer.”—Serena Stockwell
Schoenborn NL, et al JAMA Intern Med
2017 Jun 12 [Epub ahead of print]; Torke AM. JAMA Intern Med
2017 Jun 12 [Epub ahead of print].