Improving End-of-Life Care and Advance Care Planning for Frail Older Adults in Canada

Abstract

We present five Key Concepts that describe priorities for improving end-of-life care for frail older adults in Canada, and recommendations based on each Key Concept. Key Concept #1: Our end-of-life care system is focused on cancer, not frailty. Key Concept #2: We need better strategies to systematically identify frail older adults who would benefit from a palliative approach. Key Concept #3: The majority of palliative and end-of-life care will be, and should be, provided by clinicians who are not palliative care specialists. Key Concept #4: Organizational change and innovative funding models could deliver far better end-of-life care to frail individuals for less than we are currently spending. Key Concept #5: Improving the quality and quantity of advance care planning for frail older adults could reduce unwanted intensive care and costs at the end of life, and improve the experience for individuals and family members alike.

A rapid scoping review of end-of-life conversations with frail older adults in Canada

“…7 Compared with non-frail older adults with multimorbidity, frail older adults have an increased risk of sudden decline and death; thus, end-of-life (EOL) conversations with this population are crucial. 8 End-of-life conversations include advance care planning (ACP), goals-of-care discussions, and health care consent. 9 Advance care planning elicits patients' values and preferences for future care to ensure that substitute decision makers (SDMs) are prepared to make treatment decisions on behalf of patients if they are called on to do so.…”

“…[27][28][29][30] Ten articles were commentaries. 3,4,8,[31][32][33][34][35][36][37] Three articles reported findings from quantitative studies. [38][39][40] Three articles reported findings from qualitative studies.…”

“…[40][41][42] The literature identifies this as a concerning gap in practice given the widespread consensus that medical care should be centred on patients' wishes and preferences. 4,8,28,31,[32][33][34]41,42,44 Lack of patient knowledge to make informed EOL decisions. The literature also states that frail older adults and their care partners often do not make informed health care decisions because they lack sufficient understanding about their current health status, the risks of treatments, and their underlying side effects, benefits, and alternatives.…”

“…The literature also states that frail older adults and their care partners often do not make informed health care decisions because they lack sufficient understanding about their current health status, the risks of treatments, and their underlying side effects, benefits, and alternatives. 4,8,28,[31][32][33][34]41,42,44 This lack of knowledge may contribute to the ongoing trend where frail older adults, care partners, and clinicians choose or recommend more aggressive therapies such as the use of invasive ventilation, dialysis, 27,40 cardiopulmonary resuscitation, 34 implantation of a defibrillator, 29 and certain surgeries, 35 which often do not extend life for these patients but can lead to technologically mediated deaths or further decline. 3,4,27,29,[33][34][35]37,40,44 Move to receive "appropriate" medical care.…”

Levels of Medical Intervention and End-of-Life Practices in Long-Term Care Centres

“…( 3 – 5 ) Communication between clinicians and patients, or their designated substitute decision-makers, appears of utmost importance to support quality end-of-life care practices in LTCCs. ( 4 , 6 ) Through open and clear communication, preferences regarding goals of care in end-of-life are sought in order to avoid futile interventions, and to ensure that distressing symptoms are evaluated and relieved. ( 7 – 9 )…”