This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #4, #27, #30
The percentage of older adults in the United States is increasing, and this population tends to have multiple chronic conditions with acute exacerbations and progressive debility.
Highlighting the ideal delivery of palliative care across the care continuum, and contrasting this model with the deficiencies present in the current system, we illustrate areas for improvement for the delivery of palliative care for older adults.
Key Clinical Point
The palliative care needs of older adults differ from those of children and younger adults and are best served by delivering palliative care services in a variety of care settings.
Consider Mrs. M, an 88-year-old woman with moderate congestive heart failure, mild cognitive impairment, and painful osteoarthritis, who ambulates with the assistance of a walker. Mrs. M is widowed and lives in assisted living. Her daughter, who lives in the same city, provides assistance with medications, and accompanies her to appointments with her primary care doctor and cardiologist. Mrs. M enjoys her weekly routine, which includes caring for her small dog, meals with friends at the assisted living, and trips to church with her daughter on Sundays. This routine is stable until one day when she falls and breaks her hip. She undergoes a surgical “pinning” procedure at the local hospital. Her posthospital course is complicated by delirium and pain. She is transferred to a skilled nursing facility for rehabilitation. After 2 months in the skilled nursing facility, Mrs. M is unable to return to the assisted living facility because she consistently requires daily assistance with bathing and dressing. She moves in with her daughter and enrolls in a home-based primary care program. A new routine is established, and she enjoys regular visits from her great grandchildren. However, 2 years later, her cognitive impairment has progressed to mild dementia. Overwhelmed with Mrs. M’s daily care needs, her daughter admits her to a nursing home. Mrs. M is hospitalized three times over the next year. She enrolls in hospice after the third hospitalization and survives another year.
The case of Mrs. M illustrates the need for a truly integrated system of palliative care that meets the medical and social needs of older adults across the care continuum. Palliative care is fundamentally about improving quality of life for persons with serious and advanced illness. The types of care that would help support Mrs. M’s quality of life vary as her health circumstances and care settings change. These include, but are by no means limited to (1) a home safety evaluation, including pragmatic steps such as the installation of grab bars and a shower chair; (2) an advance care planning conversation that helps her daughter understand her mother’s goals, values, and preferences; (3) a provider who can care for her across settings; (4) ...