Introduction

Geriatric Essentials

• Health care practitioners should provide dying patients and their family members with clear, realistic information about their illness and its course.
• Patient preferences should be accommodated as much as possible when care is planned. For this reason, elderly people, even those who are healthy, should be encouraged to document their wishes for end-of-life care and to discuss these instructions with their physicians.
• Control of symptoms, based on their cause when possible, is essential. Concern about drug dependence should not interfere with symptom control.

Helping patients and their family members and friends find comfort in the experience of dying is often more important than adhering to medical routines or correcting symptomless physiologic abnormalities. However, distressing symptoms should be prevented or relieved as effectively as possible. Preventing suffering is also important. Suffering is a global perception of distress caused by factors that, together, undermine quality of life; these factors include pain, dyspnea, delirium, asthenia, physical impairment, psychologic disturbances, and financial, social, family, and spiritual concerns. Anorexia may be distressing to the patient but is more likely to distress family members and health care practitioners.

People differ in what they consider important, especially when facing death. Some people search for closure. They reach out to friends and family members to share time and express love, complete projects important to their lives, and tie up loose ends. Often, with appropriate support, people die at a time and in a way that allows them to experience satisfying closure. To experience such closure, people need to be given realistic information about their illness and prognosis. Even people who choose not to accept their illness can benefit from information provided in a tactful way. Some people cannot accept their imminent mortality and avoid such closure. For some, life is to be prolonged, even at the cost of pain, marked confusion, or severe respiratory distress. For others, quality of life is the overarching concern; they prefer comfort measures rather than a prolonged period of disability.

Accommodating patient preferences as much as possible is essential when planning care. For example, some patients may prefer relief from pain, even when doing so may increase sedation; others may prefer to avoid sedation, even when doing so involves tolerating pain. Truth telling is important. Practical information needs to be provided so that patients and family members can understand realistic options. For instance, CPR is of little benefit to patients with metastatic cancer or end-stage dementia; if aware of this information, most patients would choose to forgo CPR, as would their family members. Respecting autonomy is important, but patients and their family members cannot have true autonomy unless they are given adequate guidance. Some patients choose to receive treatments that are ineffective. However, health care practitioners should not provide treatment that is harmful or not helpful.

Health care practitioners should know local laws and institutional policies governing living wills, durable power of attorney, and procedures for forgoing resuscitation and hospitalization. Such knowledge helps ensure that patients' wishes are followed when patients are no longer able to direct their own care. Patients, while they are still able, should be encouraged to document their wishes for end-of-life care and to discuss these instructions with their physicians.

Supportive care may be the only realistic goal for a dying patient. Medical management of troubling symptoms can enable patients, family members, and friends to avoid needless suffering and to share valuable time. However, to say that a patient's care has changed from curative to supportive or from treatment to palliation is an oversimplification of a complex decision process.

When death is imminent, patients and their family members may wish to begin focusing on planning end-of-life care, relieving symptoms, maximizing function, and attending to spiritual issues. Thus, many patients ask whether the time until death can be predicted. Prediction can be difficult; many people live for months or years in a very fragile state of health. Predicting time until death is particularly difficult for disorders in which death tends to come suddenly and without reliable warning signs (eg, heart failure, emphysema). For other disorders (eg, commonly cancer), recognizable changes may presage death by several weeks or months. Still, most health care practitioners overestimate the time until death by a wide margin, possibly depriving patients and their family members of the opportunity to plan for death. Health care practitioners should estimate time until death for patients and their family members using 1 of 4 categories: hours to days, days to weeks, weeks to months, or months to years. Estimates of a specific time unit (eg, 6 mo) are usually inaccurate.

Effective care for dying patients usually involves a team of caregivers because no one caregiver is available 24 h/day and because the skills and perspectives of several disciplines are needed. Palliative care or hospice teams anticipate potential problems and make appropriate arrangements (eg, obtaining supplies or opioids in anticipation of a potential emergency). When death is imminent, an experienced team member can comfort and support family members and friends and may prevent an inappropriate call to the emergency medical system. Dying patients often have spiritual needs that should be recognized, acknowledged, and addressed.

This topic was last updated July 2006.