NRNP 6547 Week 10 Position Paper Example

Position Paper: The Primary Care Clinician Should Start the First Serious Illness Conversation, Before the Crisis

Student Name

College of Nursing, Walden University

NRNP 6547: The Aging Experience

Instructor Name

Month Day, Year

Position Paper: The Primary Care Clinician Should Start the First Serious Illness Conversation, Before the Crisis

Thesis

For an older adult whose clinician would not be surprised by that person's death within a year, the first serious illness conversation should be started by the primary care clinician at a scheduled outpatient visit, not left to a hospital team during a crisis.

This is narrower than the claim that end-of-life care should be improved, which nobody disputes. It names a person, the primary care clinician, who may be a nurse practitioner; a place, the outpatient visit; a trigger, the surprise question; and an alternative it rejects, the hospital conversation held after an emergency admission. Each of those could be argued differently, which is what makes the thesis worth defending.

Support 1: Conversations Held Earlier Change the Care People Receive

In a multisite prospective cohort of 332 patients with advanced cancer and their caregivers, the 37% of patients who reported an end-of-life discussion with a physician before enrollment received less aggressive care in their last week of life, including lower rates of mechanical ventilation and resuscitation, and entered hospice earlier (Wright et al., 2008). Their caregivers also adjusted better in bereavement. The discussions in that study were measured before a final crisis; their value lay in having happened while the patient could still act on them.

A hospital conversation during an emergency admission happens under the worst conditions for this. The patient may be delirious, sedated, or in pain; the family is frightened; and the clinicians are strangers who must ask about values and code status in the same hour they are stabilizing a failing organ. A conversation started months earlier, by someone who knows the patient, lets the hospital team inherit a decision rather than force one.

Support 2: The Surprise Question Gives Primary Care a Workable Trigger

The surprise question asks, "Would I be surprised if this patient died in the next 12 months?" A systematic review and meta-analysis of 16 studies and more than 11,000 patients found a pooled sensitivity of 67% and specificity of 80% for death within 6 to 18 months (Downar et al., 2017). As a precise prognostic test that is mediocre, and it performs worse for noncancer illness than for cancer. As a trigger for a conversation, it is sufficient: it is fast, needs no equipment, and can be asked at every chronic care visit. The primary care clinician who has followed a patient through several years of heart failure or lung disease is the person best placed to answer it, because the question depends on noticing trajectory, not a single set of values.

Support 3: Structured Outpatient Programs Make the Conversation Happen

Conversations do not happen reliably when they depend on individual clinicians remembering to have them. In a cluster randomized trial in outpatient oncology, the Serious Illness Care Program combined clinician training, a conversation guide, and reminders; 34 of the 39 clinicians who received a reminder completed at least one conversation, with a median length of 19 minutes (Bernacki et al., 2019). The trial did not show a difference in its primary end-of-life outcomes, a result the authors attribute partly to measurement and sample size, but patients in the intervention group had less moderate to severe anxiety and depression at 14 weeks. The program shows that ordinary outpatient clinicians, prompted and equipped, will hold these conversations, and that patients are not harmed by them. The program was designed around scheduled outpatient visits. The same components, a trigger, a guide, and a reminder built into the visit, fit primary care, where most older adults with chronic illness are seen most often.

The Strongest Objection

The strongest objection, stated as its proponents would state it: "Primary care visits are already too short to manage blood pressure, diabetes, and screening, and primary care clinicians are not trained for these conversations. The surprise question is inaccurate; with a positive predictive value near 37%, most patients who trigger a conversation will not die within the year (Downar et al., 2017). Pushing primary care to start these discussions will produce hurried, poorly handled talks with patients who are not dying, frighten them, and crowd out the chronic care that keeps them well. Specialists and hospital palliative care teams have the training and the time; the conversation belongs with them."

The objection deserves an answer in three moves.

First, the conversation is not a prediction of death. A serious illness conversation asks what matters most to the patient, what they fear, and what they would trade for more time. Those answers are worth knowing whether the patient dies in 12 months or in five years. A false positive costs one conversation that will be useful later; a false negative can cost an intensive care death with no known wishes. The surprise question is a threshold for asking, not a diagnosis.

Second, the fear of harm is not supported by the evidence. In the cohort study, patients who had end-of-life discussions did not have higher rates of major depression or report more worry than patients who did not (Wright et al., 2008). In the outpatient trial, anxiety and depression symptoms were lower, not higher, among patients whose clinicians had been trained to hold these conversations (Bernacki et al., 2019).

Third, the training gap is real but closable, and closing it is cheaper than the alternative. In the Serious Illness Care Program, nearly all the oncology clinicians trained rated the training as effective, and most went on to use a structured guide in practice (Bernacki et al., 2019). There will never be enough palliative care specialists for every older adult with a serious illness. Specialists should take the complex cases, and primary care should start the ordinary ones. The time cost is also front-loaded: a first conversation takes longer than a medication refill, but later visits can revisit it briefly.

Two Smaller Objections

"Some patients do not want to talk about it." That is true, and the clinician should ask permission and accept a refusal. But a patient cannot decline an offer that is never made, and the thesis concerns who starts the conversation, not whether it must be finished on the day.

"Hospital-based advance care planning already works." In a randomized trial of 309 medical inpatients aged 80 and older, facilitated advance care planning in hospital made it much more likely that patients' end-of-life wishes were known and respected, and reduced stress, anxiety, and depression among family members of those who died (Detering et al., 2010). The trial shows that the conversation helps. It does not show that the hospital is the best place to start it: the participants were competent enough to take part, and many patients admitted in crisis are not. Starting in primary care reaches people before that window closes.

Conclusion

For an older adult whose clinician would not be surprised by that person's death within a year, the first serious illness conversation should be started by the primary care clinician at a scheduled outpatient visit, not left to a hospital team during a crisis. If that were accepted, the surprise question would become a routine part of chronic care visits for older adults, and a hospital admission would open with the team reading a patient's documented goals rather than asking for them for the first time.

References

Bernacki, R., Paladino, J., Neville, B. A., Hutchings, M., Kavanagh, J., Geerse, O. P., Lakin, J., Sanders, J. J., Miller, K., Lipsitz, S., Gawande, A. A., & Block, S. D. (2019). Effect of the Serious Illness Care Program in outpatient oncology: A cluster randomized clinical trial. JAMA Internal Medicine, 179(6), 751-759. https://doi.org/10.1001/jamainternmed.2019.0077

Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ, 340, Article c1345. https://doi.org/10.1136/bmj.c1345

Downar, J., Goldman, R., Pinto, R., Englesakis, M., & Adhikari, N. K. J. (2017). The "surprise question" for predicting death in seriously ill patients: A systematic review and meta-analysis. CMAJ, 189(13), E484-E493. https://doi.org/10.1503/cmaj.160775

Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., Mitchell, S. L., Jackson, V. A., Block, S. D., Maciejewski, P. K., & Prigerson, H. G. (2008). Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA, 300(14), 1665-1673. https://doi.org/10.1001/jama.300.14.1665