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Canadian Family Physician•Le Médecin de famille canadien211
Commentary
The PAUSE approach to practising in long-term care
Henry Yu-Hin Siu
MD MSc CCFPO
ur population is aging. Recent census forecasts have predicted that by 2036, the population of seniors older than 65 years of age will double to 10.4 million.1 Subsequently, the population of frail elderly, defined as those older than 65 years of age who are dependent on others for their activities of daily living and are often living in institutional set- tings, will also increase.2 The 2004 National Physician Survey showed alarmingly that only 1 in 8 family phy- sicians in Canada worked in the long-term care (LTC) setting.3 The 2010 National Physician Survey showed improvement, with approximately 1 in 6 family physi- cians actively involved in LTC.4One solution to this problem has been the introduc- tion of a geriatric and LTC component in the family medicine residency curriculum. However, despite this addition, family medicine residents are still reluctant to work in LTC. Some perceived barriers include a lack of a standard approach to managing frail elderly patients, a lack of mentorship during the initial stages of prac- tice, and variable clinical experiences in LTC during residency training.5 As a result, renewed emphasis is now being placed on addressing these barriers to practice, as well as generating and cultivating resident awareness and interest in care of the elderly.6
Why is LTC unique?
Long-term care is unique because the patients within LTC are unique. The combination of relatively short life expectancy7; a paucity of evidence; increased medication burden,8 administrative pressures,9 and medical complexity9; as well as caregivers’ unique experience10 result in a heterogeneous patient popu- lation that makes navigating the fine line between intervening to the detriment of the patient and not investigating appropriately quite difficult. A systematic review reported the median prevalence of dementia in LTC patients was 58%.11 As the severity of cognitive impairment increases, family members are required to take on an increasingly active role as substitute decision makers for their loved ones in LTC; this can be challenging. Cultural factors, family dynamics, the family’s desire to extend life, the perception that the
hospital can provide better care, and infrequent com- munication with LTC staff can result in disagreements between the LTC physician and the family regard- ing a patient’s direction of care.12 Disagreements over issues such as discontinuing a long-term medica- tion, the choice to not investigate a potential cancer diagnosis, the decision to not transfer the patient to the emergency department for an assessment, or the decision to deem a patient’s condition palliative can become heated and result in physician dissatisfaction with working in LTC.13
The PAUSE approach to LTC
Modeled after an existing practice framework for poly- pharmacy in LTC,14 PAUSE (philosophy of care, assess- ing the evidence, understanding expectations, simplify, evolution of care) was developed to address a specific barrier identified by family medicine residents: the lack of a standard approach to frail elderly patients.5 Key themes from earlier reviews informed the develop- ment of the different components of PAUSE,15,16 which was thought to be more useful than providing a check- list of defined roles for LTC physicians. The PAUSE approach (Table 1) pragmatically takes LTC physi- cians through 5 reflective and interconnected ques- tions and considerations to address clinical issues that might arise in LTC. Through iterative feedback from family medicine residents during their LTC rotations, PAUSE was refined to produce this current version.
The 5 components of PAUSE are the physicians’
rationale for their actions (philosophy of care), the evidence supporting an intervention (assessing the evidence), the expectations of care (understanding expectations), the coordination of care (simplify), and questions that arise when there is a substantial change in medical status (evolution of care).
Philosophy of care. This first question asks phy- sicians to reflect on their own practice philosophy within LTC. Physicians need to determine whether their main goal for LTC patients is to maximize qual- ity of life or to actively manage and optimize chronic medical conditions, or whether it is somewhere in between. Recognizing this at the outset will help physicians communicate consistently with patients and their families, as well as offer a basis for making ongoing clinical decisions. It is important to note that a physician’s philosophy of care can vary depending on the patient; this flexibility helps the physician adapt to the heterogeneity seen among LTC patients.
This article has been peer reviewed.
Can Fam Physician 2015;61:211-3
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de mars 2015 à la page 218.
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Vol 61: march • mars 2015Commentary | The PAUSE approach to practising in long-term care
Assessing the evidence. The evidence for most inter- ventions in LTC is sparse; commonly used risk calcu- lators (eg, CHA2DS2-VASc [congestive heart failure;
hypertension; age ≥ 75 years; diabetes mellitus; stroke or transient ischemic attack; vascular disease; age 65 to 74 years; sex category], Framingham, FRAX [Fracture Risk Assessment Tool]) do not take into consideration factors relevant to LTC such as comorbidities, treat- ment burden, and patient prognosis. As a result, it is important to stay up to date on the interventions and screening assessments that have substantial support in the LTC and frail elderly populations17 including assess- ments for polypharmacy,14 depression,10 and pain.18 It is important to remember that the evidence that does exist must be judiciously applied with input from the patient and the family. This results in a practice that is evidence informed, rather than rigidly evidence based.
Understanding expectations. Previous research shows that substitute decision making is stressful and substitute decision makers often feel unprepared and unsupported in making medical decisions in the LTC setting.10,19 A qualitative study of caregivers and fam- ily members of LTC residents revealed that their expec- tations revolved around addressing basic care needs, assurance that their loved ones were safe, timely com- munication, and a sense of community for their loved ones in the LTC setting.20 However, these findings seem to contradict clinical experience, as some phy- sicians report experiences of unrealistic expectations, excessive demands, and criticisms by relatives.13,21 Navigating guilt, stress, unspoken relief, and resum- ing a life without the role of being a full-time caregiver requires understanding, patience, and empathy from the physician.20,22,23 The LTC physician needs to give family members time to come to terms with admitting their loved ones into LTC facilities.
Therefore, forming a strong collaborative relation- ship from the beginning with patients and their fami- lies allows for expectations on both sides to be shared openly. Prioritizing the development of this therapeutic relationship between physicians and family members might help to address the feelings that family mem- bers often have of being lost, intimidated, and over- whelmed10 and foster sources of satisfaction for LTC physicians including being able to provide care and improve the health of medically complex older patients as part of a multidisciplinary team.13
Simplify. This question challenges the clinician to take an active role in simplifying and communicating expectations of care. Simplifying care is not just about reducing the number of medications or investigations ordered. Although minimizing inappropriate interven- tions is important, this component recognizes that the quality of care is not associated with the number of tests and investigations ordered. On another level, sim- plifying care is about creating a management plan and communicating it to the rest of the allied health team;
the plan should be consistent with the expectations and determined goals of care of patients and their caregiv- ers. Consistency in how medical decisions are made on behalf of patients helps to minimize confusion between caregivers and the medical team. It also helps to pre- vent inappropriate or unnecessary investigations and medications when acute medical issues do arise in LTC.
Evolution of care. It is inevitable that things will change over the course of a patient’s stay in LTC. The LTC physician needs to remain willing to communi- cate with family as a patient’s medical status changes in order to develop the best care plan possible. This includes ongoing discussions regarding active disease
Table 1. The PAUSE approach to practising in long-term care
COMPOnEnT qUESTiOn Or COnSiDErATiOn
Philosophy of
care Ask:
• What are the medical, ethical, social, and cultural principles that will guide my decisions and discussions with the family?
Assessing the
evidence Consider:
• Comparing evidence-based medicine vs evidence-informed medicine
• Developing critical appraisal skills
• Cultivating reliable sources for gathering up-to-date evidence
Understanding expectations
Ask:
• What are the expectations of the patient, his or her family members, and his or her substitute decision maker?
• What are my expectations for this patient’s care?
• How can I align the multiple expectations to foster collaboration with the family?
Simplify Ask:
• Does this patient require this medication?
What are the risks of continuing or discontinuing this drug?
• Is this intervention or test absolutely necessary? What will I do with the information afterward?
• How do I communicate this plan consistently to the rest of the health care team?
Evolution of care
Ask:
• Has there been a status change in the patient?
• Have the caregivers or family members been informed of this status change?
• Have the goals of care changed since the change in status?
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The PAUSE approach to practising in long-term care | Commentary
management, as well as proactive discussions regard- ing the prognosis and treatment expectations as the patient’s functional status changes or declines.
incorporating the PAUSE approach
Merely having an LTC experience in residency train- ing is insufficient to develop confidence and enthusi- asm in family medicine residents for future LTC practice.
A more opportune time to first introduce this practice framework might be at the undergraduate clerkship level. By incorporating PAUSE earlier in medical train- ing, medical learners could be exposed to this approach earlier, repeatedly, and with increasing depth through- out their medical education.24 For example, PAUSE can be introduced didactically at the family medicine clerk- ship level; subsequently PAUSE can be reinforced at the residency level in the LTC setting by LTC preceptors.
Through active modeling, residents can observe how PAUSE can frame and guide week-to-week clinical deci- sion making as well as support effective communica- tion with family members in LTC. However, this does not have to be limited to resident learners; physicians con- sidering practices in LTC would also benefit from men- torship and ongoing communication with tenured LTC physicians on how PAUSE might be used to structure and support their new practices.
Although this approach does not directly address issues such as remuneration or time constraints,5 PAUSE offers a possible solution to a perceived practice gap.
For PAUSE to be most effective, existing LTC physicians need to take an active role in mentoring residents and physicians new to LTC. Therefore, for the existing LTC physician, PAUSE offers more than just a pragmatic approach to practice in LTC, it serves as an encourage- ment to continue engaging and supporting the develop- ment of our future LTC physicians.
Dr Siu is Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont.
competing interests None declared correspondence
Dr Henry Yu-Hin Siu; e-mail siuh3@mcmaster.ca
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
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