Improving End-of-Life Care for Older Adults: An International Challenge

Abstract

ND-OF-LIFE care, a dimension of care that is providedcommonly within the context of both geriatric andpalliative care, is now receiving more attention as an area ofstudy. Despite a growing body of literature addressing careat the end of life, there is still little regarding how this care isprovided for many geriatric populations. Two studies in thepresent issue of the Journal, though reflective of the country-specific organization of health and end-of-life care,demonstrate the international challenges to be faced inproviding optimal end-of-life care for older adults.Menec and colleagues (1) concern themselves with healthservices use for older Manitobans nearing the end of life.The researchers demonstrate substantial differences in carepatterns among younger-old (65–74 years), old (75–84), andolder-old ( 85) age groups. Perhaps not surprisingly,a much greater proportion of older-old deaths (nearly half)occur in long-term care institutions; however, also in thatoldest group, deaths that occur at home are less likely tooccur with the provision of in-home care. Further, the oddsof hospital use at 1 month and 6 months prior to death arelower in the oldest-old category versus the middle group,and intensive care unit use for the same period declinessignificantly by age grouping. Among all older adults, fewerthan 30% of deaths occurred in the home, the setting wheremany patients state they would prefer to die.The fact that almost one half of all older adults in the 85þage range die in long-term care settings highlights the needfor improved palliative care in nursing homes. As noted byTeno and others, nursing homes have been among theslowest to adopt palliative care approaches to dying patients(1–3). Long-term care settings are often hindered by lack ofknowledge regarding palliative care interventions at the endof life and a more rehabilitative orientation toward care,which may no longer be appropriate for these patients. Thisstudy provides compelling data on the large numbers ofolder adults in long-term facilities who could benefit fromgood end-of-life care.De Gendt and colleagues (4) take a more granular look atdecision-making and advance care-planning practices inacute geriatrics wards in Belgium. Their finding thatapproximately one fifth of patients have do-not-resuscitate(DNR) orders is similar to an older rate reported for anAmerican ward (5), but much lower than the prevalence ofDNR orders on Dutch geriatrics wards (6,7). The research-ers focus on the process by which DNR status is obtainedand observe marked variation in practice patterns forprocuring DNR orders. Even in an acute geriatric setting,the bulk of orders appeared to be obtained very late in thecourse of disease with little use of advance directives, orconsultation with patients’ general practitioners or thepatients themselves. While head nurses were very frequentlyconsulted prior to writing the order, geriatricians tended tomake the decision during daily rounds rather than in weeklyinterdisciplinary team meetings. Of greatest concern was therelative infrequency of patient and family involvement inthese treatment decisions.Both studies highlight gaps in current end-of-life care forolder adults. The absolute number of older adults receivingend-of-life care in institutional settings (hospital or nursinghome) emphasizes the need for additional palliative caretraining. The continued disconnect between treatmentdecisions at the end of life, advance care planning, andpatient autonomy suggest opportunities for improvement insystems-based practice. Indeed, in De Gendt’s cohort,simple practices such as having a DNR policy substantiallyimproved information about DNR status.The settings of long-term care and community-basedadvanced-illness care serve as natural intersection points forpalliative care and geriatric care providers to collaborate andinfluence policy for better care for older patients at the end oflife. Menec and De Gendt’s studies show us that, as providerswithin existing systems of care, we have a long way to go toproviding optimal end-of-life care to aged adults.