Pearl 1: When Should I Start “I’m Worried…” Conversations?

Most clinicians in clinic have a sense that a patient “isn’t doing well” when they read through a patient’s chart and note recurrent hospitalizations or ER visits.  The repeated hospitalizations may be even more concerning if this is despite the patient undergoing medical treatments for active medical issues (such as for cancer or advanced congestive heart failure). 

They may glance at the vital signs and note the change in weight compared to previous visits.  They may watch how their patient moves about the exam room, perhaps this time sitting in a wheelchair whereas before their patient had ambulated with a walker.

If an investigation with labs and possibly imaging for potential reversible causes, medication review for potential side effects or interactions, physical therapy referrals, nutritionist referrals, diet education, and exploration of social determinants has already been attempted - and your patient still demonstrates and describes decline with day to day functioning to the point of requiring assistance - that may be the time to start “I’m worried…” conversations about their likely downward health trajectory and possibly also prognosis.