Choosing Wisely - EBM Recommendations to Avoid Waste

The ABIM Foundation's "Choosing Wisely" initiative has some implications for end-of-life interventions.  Basically, 9 U.S. specialty societies representing 374,000 physicians developed lists of "Five Things Physicians and Patients Should Question" in recognition of the importance of physician and patient conversations to improve care and eliminate unnecessary tests and procedures.  These lists represent specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.  Here are two examples from the American Society of Nephrology's list:

• Don’t perform routine cancer screening for dialysis patients with limited life expectancies without signs or symptoms.  Due to high mortality among end-stage renal disease (ESRD) patients, routine cancer screening—including mammography, colonoscopy, prostate-specific antigen (PSA) and Pap smears—in dialysis patients with limited life expectancy, such as those who are not transplant candidates, is not cost effective and does not improve survival. False-positive tests can cause harm: unnecessary procedures, overtreatment, misdiagnosis and increased stress. An individualized approach to cancer screening incorporating patients’ cancer risk factors, expected survival and transplant status is required.

• Don’t initiate chronic dialysis without ensuring a shared decisionmaking process between patients, their families, and their physicians.  The decision to initiate chronic dialysis should be part of an individualized, shared decision-making process between patients, their families, and their physicians. This process includes eliciting individual patient goals and preferences and providing information on prognosis and expected benefits and harms of dialysis within the context of these goals and preferences. Limited observational data suggest that survival may not differ substantially for older adults with a high burden of comorbidity who initiate chronic dialysis versus those managed conservatively.