The Problem of Predictability

Among physicians and other healthcare professionals, placing trust in evidence-based diagnosis and treatment creates a foundation for providing patient care with relatively predictable outcomes. But how do we respond when the unexpected happens? Do we blame ourselves? The evidence? Or the unknowable? Often recited as a prayer, there is a common expression in which wisdom is called upon to distinguish and accept the things in life that can be controlled from the things that cannot. This issue of Annals of Long-Term Care: Clinical Care and Aging^® examines this sentiment from several perspectives, discussing how to provide the best care possible when unlikely outcomes occur.

In a Perspectives article, Jacqueline Vance, RNC, and colleagues explore the question: when do poor outcomes constitute poor care? When a poor outcome occurs, such as a fall, it’s common to assume that it resulted from poor care, implying a degree of failure. But that’s not always the case. As long-term care professionals are called upon to reduce avoidable and unnecessary outcomes, it’s essential to distinguish poor care from unpreventable outcomes. This article review four common syndromes in elderly residents: pressure ulcers, falls, weight loss/malnutrition, and dehydration. The authors outline the steps that a multidisciplinary care team should take to ensure these syndromes are appropriately assessed, managed, and documented. Only after these steps have been exhausted can an outcome be considered unpreventable, they argue. At the end of the article, there is a supplementary tip sheet outlining the elements of a care plan for each of the four syndromes.

Documented discussion is one of the common threads for ensuring the best care possible in each of the four syndromes. This is especially true in making end-of-life decisions. In a case report, Michael Gordon, MD, and Giulia-Anna Perri, MD, explore through an illustrative case how families’ emotional dynamics can complicate end-of-life discussion. The case patient passed away shortly after he was admitted to a palliative care unit. The patient’s daughters, who had been openly disagreeing with each other and with staff about his care, created a tense, adversarial atmosphere in their father’s final days. After the patient’s death, the care team reflected on what could have been done differently. They recognized that despite their attempts to facilitate discussion among the family and patient, a preadmission consultation that explained the patient’s prognosis and likelihood of a sudden decline could have prevented conflict by establishing expectations.

But no matter how predictable the occurrence of death, the dying process is never free of conflict and grief. In a poignant poem titled “Precious Time”, the authors reflect on the internal conflict that many physicians and nurses face when caring for an aging and dying patient. They illustrate how to peacefully accept death’s inevitability by acknowledging that time is cherished because it is limited.

In this issue, you will also find a case report highlighting an area of therapeutics in which there is great variability and little reliability among elderly patients: anticoagulants. Warfarin has been the mainstay of oral anticoagulation therapy for stroke prevention, but its limitations have given rise to a plethora of new oral anticoagulants, such as dabigatran. Although the drug has many advantages compared to warfarin, the safety of dabigatran has not been extensively evaluated in elderly patients. Determining the appropriate dosage of dabigatran to avoid risks, such as bleeding toxicity, is difficult in elderly patients due to the presence of multiple comorbidities and other medications that can impair renal function. The authors present the case of an elderly patient who experienced rapid functional decline leading to hospice care as a result of a massive upper gastrointestinal bleed while taking dabigatran. The case report should not deter providers from prescribing dabigatran, but it should instill caution and increase clinical vigilance for the many variables that can affect the drug’s safety in elderly patients.

Please also look for the next article in our Ask the Expert series, which reviews important points about the current flu season with a CDC medical epidemiologist. The report is a reminder that although flu seasons are unpredictable, older adults and long-term care staff should reduce their risk of infection by receiving an annual vaccination. But as vaccine efficacy is never 100%, this report also reviews recommendations for prescribing antiviral medication.

We hope you enjoy the articles in this month’s issue of the journal. As always, thank you for reading!