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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #1, #4, #7, #12, #13, #22, #23, #24, #26, #27, #28

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LEARNING OBJECTIVES

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Learning Objectives

  • Identify the palliative needs of an aging population and recognize the potential benefits palliative care delivers in collaboration with or as part of geriatric medicine practice.

  • Describe the unique palliative care needs of special populations including patients with dementia, frailty, or multimorbidity, as well as the needs of lesbian, gay, bisexual and transgender patients, and ethnic and culturally diverse populations.

  • Distinguish the various advance care planning formats and tools and adapt a three-step process to prognostication in older adults as part of advance care planning.

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Key Clinical Points

  1. Multiple randomized trials show palliative care improves outcomes including quality of life, satisfaction with care, reduced famdistress, and increased hospice utilization and may be associated with longer life expectancy.

  2. For older adults with multiple chronic illness, a five-step approach to palliative care includes the following:

    1. Determine patient preferences.

    2. Interpret the evifor treatment with recognition of the limitations applying it to an older adult population.

    3. Let prognosis frame clinical management decisions.

    4. Consider treatcomplexity and feasibility as part of management decisions.

    5. Optimize therapies and care plans.

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INTRODUCTION

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Palliative medicine is an essential skill set for health care professionals practicing geriatric medicine or simply caring for older adults. Supporting the needs and goals of older adults as they age is a complex process that often involves a balance between competing goals of life prolongation, functional status preservation and restoration, risk and harm mitigation, and symptom relief. Palliative care aims to ensure that these goals match the individualized care plans through interprofessional care and careful communication and goal setting.

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Palliative care for older adults poses distinct challenges. For older patients with diminished reserve to respond to stressors, the potential for harm of interventions can be substantially riskier than younger populations. Cognitive impairment may limit the participation of patients at times when the most difficult decisions need to be made. The interaction of multiple illnesses in multimorbidity may reduce the potential benefit of interventions, which are otherwise therapeutic in single disease state.

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It is appropriate given the aging population and the increasing evidence base for palliative care that this edition of Hazzard’s Geriatric Medicine has significantly expanded geriatric palliative medicine content. For this chapter we will focus on the palliative needs of an aging population and examine special management issues facing the geriatrician, including cognitive impairment, multimorbidity, and frailty. We will also address issues related to prognostication and advance care planning. Subsequent chapters within the palliative care section will focus on geriatric palliative care issues related to pain management, effective communication, palliative care delivery systems, spirituality, and ethics.

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DEFINING PALLIATIVE CARE

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Palliative care aims to improve the quality of life ...

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