Serving the Very Sick, Very Frail, and Very Old: Geriatrics, Palliative Care, and Clinical Ethics

Abstract

How can we provide the best care for growing numbers of very frail, very sick, or very old people? The disciplines of geriatrics, palliative care, and clinical ethics each have a good deal to offer to improve care for elders, yet each field is saddled with heavy historical baggage. Using a case as a springboard, we address specific strengths and shortcomings of each field, and what these disciplines can learn from each other. Geriatrics is currently largely focused on prevention of disability, cognitive impairment, and death; it should reorganize around a palliative approach to providing care for elders living with multiple chronic conditions, disability, and dementia. Palliative care, while paying some attention to the spectrum of advanced illness, concentrates primarily on cancer; it should expand its central purpose to include providing supportive care to elders with serious illness and their caregivers. Ethics committee members and consultants principally stress individual autonomy; they need to expand their approach and develop longitudinal relationships with patients and family members, routinely incorporating them in deliberations and the crafting of recommendations. However, improving these three disciplines will only go so far toward improving the care of very frail, very sick, or very old people. What is most needed is longitudinal care provided by interdisciplinary primary care teams steeped in the core principles of all three disciplines.

The epidemiology of preexisting geriatric and palliative conditions in older adults with poor prognosis cancers

“…To our knowledge, ours is one of the first studies to describe the prevalence of both preexisting geriatric and palliative conditions in older adults with poor prognosis cancers in a nationally representative cohort. Geriatric conditions are issues that uniquely affect older adults as a process of aging, such as falls and polypharmacy 7 . Palliative care conditions are distinct because they encompass a wide range of symptoms and quality of life in patients of all ages with serious illnesses 7 .…”

“…Geriatric conditions are issues that uniquely affect older adults as a process of aging, such as falls and polypharmacy 7 . Palliative care conditions are distinct because they encompass a wide range of symptoms and quality of life in patients of all ages with serious illnesses 7 . However, there is significant overlap between geriatric and palliative care conditions 7 .…”

“…Palliative care conditions are distinct because they encompass a wide range of symptoms and quality of life in patients of all ages with serious illnesses 7 . However, there is significant overlap between geriatric and palliative care conditions 7 . Both geriatric and palliative care conditions are focused on overall well‐being, functional outcomes, advance care planning, and end‐of‐life issues 7 .…”

“…6 Older adults with poor prognosis cancers should be holistically evaluated and managed using geriatrics and palliative care principles. 7 In two recent randomized clinical trials, geriatric assessment (GA) driven recommendations and interventions have been shown to reduce grade 3-5 chemotherapy toxicity 8,9 and select geriatric syndromes, such as falls and polypharmacy. 9 GA-driven interventions also resulted in a 15% increase in advance directive completion.…”

Endovascular Treatment and Thrombolysis for Acute Ischemic Stroke in Patients With Premorbid Disability or Dementia: A Scientific Statement From the American Heart Association/American Stroke Association

“…As our societies age, the patient population with acute stroke can be expected to increasingly comprise older patients with multiple comorbidities, disability, or dementia. 61 The stroke community has an obligation to generate higher-quality data to inform stroke care in this expanding population. Several important factors must be addressed to improve the state of stroke research with regard to patients with prestroke disability or dementia (Figure 2).…”