"Choosing Wisely"- Beginning the Conversation

Andrea Yevchak, PhD, GCNS-BC, RN

Andrea Yevchak is Assistant Professor at the Duquesne University School of Nursing in Pittsburgh, Pennsylvania.

Conversations happen across clinical settings every day. In conjunction with her family, a mother makes decisions about radiation, chemotherapy, and surgical treatments for breast cancer. A single man contemplates surgical removal of a portion of his colon due to cancer associated with Crohn’s disease therapies.

An older patient decides whether to continue with his chemotherapy and cancer treatments, as he experiences a significant decline in his quality of life. Two sons watch as their father suffers unnecessarily from throat cancer, not yet knowing how this will impact their future lives.

These exchanges took place between healthcare providers, patients, and families in all of these scenarios. Questions were asked and answered, but what may not have happened are the critical conversations regarding the appropriateness of some treatments.

The Choosing Wisely initiative is a potential solution to begin these important discussions.

The campaign was launched in 2012 by the ABIM (American Board of Internal Medicine) Foundation.^1,2 This national campaign is currently in phase three and has expanded internationally as well. It covers many specialty disciplines, such as cardiology, oncology, and radiology. Choosing Wisely has been lauded as an innovative method to help reduce healthcare spending in the United States and beyond.

The overarching goal of the campaign is to encourage communication between all members of the healthcare team—including the patient and family—as a mechanism to reduce unneeded or overused medical tests and procedures.³

The items included are those that are unnecessary, of limited value, or may be potentially harmful, while also addressing patient preferences during critical times of acute and chronic illness, such as with a cancer diagnosis.⁴ The campaign recognizes individual needs regarding treatment and other influencing circumstances, as it encourages the critical conversations that need to occur between healthcare providers, patients, and families.

National medical organizations and consumer- focused groups have identified their own lists, which is a unique facet of the Choosing Wisely Campaign.^1,2 Specific groups related to oncology who have created their own lists of procedures or tests or who are somehow involved in the campaign include: American Academy of Hospice and Palliative Medicine (Box); American Academy of Nursing; American Society of Clinical Oncology, Society of Gynecologic Oncology, American Society of Hematology; the Commission on Cancer, and others.¹

Lists of unbeneficial diagnostic tests, such as imaging tests to stage early breast cancers at low risk of metastasis, are mentioned, as well as recommendations for early stages of prostate cancer.

Box. Choosing Wisely: 5 Things Physicians and Patients Should Question⁵

• Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding.
• Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.
• Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals of care.
• Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.
• Don’t use topical lorazepam (Ativan), diphenhydramine (Benadryl), haloperidol (Haldol) (“ABH”) gel for nausea.

Information is available for cancer patients at the end of life including how to choose supportive care versus curative therapies and even advice on making the difficult decisions associated with a cancer diagnosis. Information is provided by Consumer Reports and other organizations that can help patients and families begin this critical step. Details are provided on questions to ask regarding length of time expected to live with treatment and to better understand treatment goals, while balancing patient preferences.

A critical step is education of all levels of healthcare providers, including nurses who are on the frontline of providing care. This aspect of project dissemination is still in the beginning stages. The American Academy of Nursing is launching a campaign specific to nurses which builds upon Choosing Wisely.

Nurses influence healthcare personal and economic expenses on a daily basis by not using evidence-based care as an example.2 Nurses can advocate for patients and families, provide education regarding best practices, palliative, and/or hospice care, and ask patients about their preferences and quality of life. Often patients and families are unaware of the choices that they may have regarding cancer care, but we can begin to openly communicate using Choosing Wisely as a stepping stone.

References

• ABIM Foundation. Choosing Wisely. http://www.choosingwisely.org. Accessed June 19, 2014.
• Disch J, Tilden V, Mason DJ, Naylor M, Cox K. Nursing’s perspective on the national campaign for Choosing Wisely. Nurs Outlook. 2013;61(6):471- 472.
• Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.
• Morden NE, Colla CH, Sequist TD, Rosenthal MB. Choosing Wisely — The Politics and Economics of Labeling Low-Value Services. N Engl J Med. 2014;370(7):589-592.
• American Academy of Hospice and Palliative Medicine. Five Things Physicians and Patients Should Question. http://www.choosingwisely.org/ doctor-patient-lists/american-academy-of-hospice-palliative-medicine/. Accessed June 19, 2014.