The Core Bereavement Items (CBI) is a commonly used measure that assesses core grief and bereavement experiences. Although previous psychometric testing has been conducted, no studies have assessed its use specifically aimed at adults aged 50 and older or for those who lost a loved one who was hospice care. This is critical, as losses and additional obstacles in bereavement compound throughout the aging process. The present study investigated reliability, content validity, and internal structure of the CBI in bereaved adults aged 50 and older whose loved one died while in hospice care (N = 205). Associations based on age, marital status, and relationship with the died patients were consistent with preexisting research. Results of a Cronbach a reliability test found that the CBI has excellent reliability in this population. Further, content validity was established based on the judgment of subject matter experts. Exploratory factor analysis supported a 1-factor structure, with all items loading as General Grief Experiences. Based on this analysis, the CBI is a valid and reliable tool when used with adults aged 50 and older.
Faire reconnaître le rôle central des aidants profanes et rappeler le caractère indispensable de leur contribution fait aujourd’hui partie des principaux besoins que les aidants revendiquent explicitement, tant vis-à-vis des professionnels avec qui ils collaborent, que vis-à-vis des pouvoirs publics. Dans un contexte de plus forte sensibilisation à leur égard, c’est aussi l’ambition de ce numéro de Gérontologie et société, qui se propose à la fois de définir et de renseigner ce que recouvre la notion de proches aidants auprès de personnes âgées mais également de comprendre la nature de leurs engagements et de leurs expériences. Comment ces aidants pensent-ils leur rôle et envisagent-ils leur situation ? Quels sont les ressorts et les logiques sociales qui déterminent leurs investissements et leurs manières d’aider ? Dans quelle mesure sont-ils épaulés et comment s’accommodent-ils des services qui leurs sont proposés ? Sur la base d’une sélection de 9 articles, retenus pour leur diversité d’approche disciplinaire et territoriale, les contributions présentes dans ce numéro offrent un témoignage concret du profil hétérogène de ces aidants, de l’extrême diversité des tâches qu’ils accomplissent mais aussi des difficultés qu’ils sont susceptibles de rencontrer au quotidien. Plus fondamentalement encore, ils interrogent la situation d’aide, l’intimité des relations entre aidants et aidés et démontrent l’impérieuse nécessité à poursuivre les efforts pour soutenir ces proches aidants dans leur travail quotidien d’accompagnement.
Elderly patients with advanced chronic kidney disease have high symptom burden, despite the progress in renal replacement therapy. Dialysis is not a good option especially for frail elderly patients with higher comorbidity rate. Integration of palliative and supportive care to conservative management improves quality of life and prolongs survival of these patients. Conservative management of symptoms, prognostication, communication of advance care plans and shared-decision making should be a part of physicians skills. There are some recommended prognostication systems in nephrology, which can help to facilitate the physician-patient communication about therapeutic goals of care. Ethical and jural aspects of the process are also very important.
BACKGROUND: Pain and symptom management is critical in ensuring quality of life for chronically ill older adults. However, while pain management and palliative care have steadily expanded in recent years, many underserved populations, such as rural older adults, experience barriers in accessing such specialty services, in part due to transportation issues. The purpose of this systematic review is to examine the specific types of transportation-related barriers experienced by rural older adults in accessing pain and palliative care.
METHODS: Studies were searched through the following 10 databases: Abstracts in Social Gerontology, Academic Search Premier, CINAHL, MEDLINE, PsycINFO, SocINDEX with Full Text, Cochrane Database of Systematic Reviews, Nursing & Allied Health Database, Sociological Abstracts, and PubMED. Studies were chosen for initial review if they were written in English, full text, included older adults in the sample, and examined pain/palliative care/hospice, rural areas, and transportation. A total of 174 abstracts were initially screened, 15 articles received full-text reviews and 8 met the inclusion criteria.
RESULTS: Findings of the 8 studies identified transportation-related issues as major access barrier to pain and palliative care among rural older adults: specifically, lack of public transportation; lack of wheelchair accessible vehicles; lack of reliable drivers; high cost of transportation services; poor road conditions; and remoteness to the closest pain and palliative care service providers.
CONCLUSION: Results suggest that rural older adults have unique transportation needs due to the urban-centric location of pain and palliative care services. Implications for practice, policy and research with older adults are discussed.
Frailty assessed using Clinical Frailty Scale (CFS) is a good predictor of adverse clinical events including mortality in older people. CFS is also an essential criterion for determining ceilings of care in people with COVID-19. Our aims were to assess the prevalence of frailty in older patients hospitalised with COVID-19, their sex and age distribution, and the completion rate of the CFS tool in evaluating frailty.
Methods: Data were collected from thirteen sites. CFS was assessed routinely at the time of admission to hospital and ranged from 1 (very fit) to 9 (terminally ill). The completion rate of the CFS was assessed. The presence of major comorbidities such as diabetes and cardiovascular disease was noted.
Results: A total of 1277 older patients with COVID-19, aged = 65 (79.9 ± 8.1) years were included in the study, with 98.5% having fully completed CFS. The total prevalence of frailty (CFS = 5) was 66.9%, being higher in women than men (75.2% vs. 59.4%, p < 0.001). Frailty was found in 161 (44%) patients aged 65–74 years, 352 (69%) in 75–84 years, and 341 (85%) in =85 years groups, and increased across the age groups (<0.0001, test for trend).
Conclusion: Frailty was prevalent in our cohort of older people admitted to hospital with COVID-19. This indicates that older people who are also frail, who go on to contract COVID-19 may have disease severity significant enough to warrant hospitalization. These data may help inform health care planners and targeted interventions and appropriate management for the frail older person.
OBJECTIVE: The aim of this project was to assess the value for money of a modified unit within a residential aged care facility (RACF) for people requiring palliative care at the end of life.
METHODS: A three-way comparison using a mixed-method costing was used to estimate the per day cost of the unit compared to care in a palliative care unit within a hospital and a standard RACF bed.
RESULTS: The cost of the unit was estimated at $242 per day (2015 Australian dollars). The palliative care hospital bed cost $1,664 per day. The cost of a standard RACF bed was $123 per day, indicating that an additional $120 per day is required to provide the higher level of care required by people with complex palliative care needs.
CONCLUSION: A modified RACF unit could provide substantial cost savings to the health budget for selected complex palliative care patients.
The Japan Geriatrics Society has so far announced "The Japan Geriatrics Society Position Statement 2012" and "Guidelines for the Decision-Making Processes in Medical and Long-Term Care for the Elderly - Focusing on the Use of Artificial Hydration and Nutrition" related to end-of-life care for older adults. In 2018, the Ministry of Health, Labor and Welfare revised the "Guidelines for the Decision-Making Processes in Medical and Long-Term Care in the End of Life," recommending the practice of advance care planning (ACP). This was the first time when the Japanese government publicized its stance on ACP. Immediately after the government's announcement, the Japan Medical Association announced its committee report, "The Super-aged Society and the End-of-life Care," which also recommended the practice of ACP. The guidelines were published when the society was experiencing substantial changes related to geriatric care in Japan, and required timely and ethically appropriate decision-making processes. However, because ACP is a concept imported from English-speaking countries, some Japanese people could find it difficult to understand the role and methodology of ACP because of differences in culture and the medical/long-term care system. Therefore, the Japan Geriatrics Society has decided to publish the "Recommendations for the Promotion of Advance Care Planning" for medical and long-term care professionals nationwide with the aim of using the recommendations on a daily basis. The society recognizes ACP as indispensable to improve end-of-life care for individuals, particularly for older adults. We anticipate that the recommendations will provide practical guidance for those strenuously working toward this goal.
The number of residents in long-term care facilities (LTCFs) in need of palliative care is growing in the Western world. Therefore, it is foreseen that significantly higher percentages of budgets will be spent on palliative care. However, cost-effectiveness analyses of palliative care interventions in these settings are lacking. Therefore, the objective of this paper was to assess the cost-effectiveness of the ‘PACE Steps to Success’ intervention. PACE (Palliative Care for Older People) is a 1-year palliative care programme aiming at integrating general palliative care into day-to-day routines in LTCFs, throughout seven EU countries.
Background: Increasing numbers of people die of the frailty and multimorbidity associated with old age, often without receiving an end-of-life diagnosis. Compared to those with a single life-limiting condition such as cancer, frail older people are less likely to access adequate community care. To address this inequality, guidance for professional providers of community health care encourages them to make end-of-life diagnoses more often in such people. These diagnoses centre on prognosis, making them difficult to establish given the inherent unpredictability of age-related decline. This difficulty makes it important to ask how care provision is affected by not having an end-of-life diagnosis.
Aim: To explore the role of an end-of-life diagnosis in shaping the provision of health care outside acute hospitals.
Design and setting: Qualitative interviews with 19 healthcare providers from community-based settings, including nursing homes and out-of-hours services.
Method: Semi-structured interviews (nine individual, three small group) were conducted. Data were analysed thematically and using constant comparison.
Results: In the participants’ accounts, it was unusual and problematic to consider frail older people as candidates for end-of-life diagnosis. Participants talked of this diagnosis as being useful to them as care providers, helping them prioritise caring for people diagnosed as ‘end-of-life’ and enabling them to offer additional services. This prioritisation and additional help was identified as excluding people who die without an end-of-life diagnosis.
Conclusion: End-of-life diagnosis is a first-class ticket to community care; people who die without such a diagnosis are potentially disadvantaged as regards care provision. Recognising this inequity should help policymakers and practitioners to mitigate it.
Most long-term care (LTC) residents are of age >65 years and have multiple chronic health conditions affecting their cognitive and physical functioning. Although some individuals in nursing homes return home after receiving therapy services, most will remain in a LTC facility until their deaths. This article seeks to provide guidance on how to assess and effectively select treatment for delirium, behavioral and psychological symptoms for patients with dementia, and address other common challenges such as advanced care planning, decision-making capacity, and artificial hydration at the end of life. To do so, we draw upon a team of physicians with training in various backgrounds such as geriatrics, palliative medicine, neurology, and psychiatry to shed light on those important topics in the following "Top 10" tips.
A transitional care pathway (TCP) could improve care for older patients in the last months of life. However, barriers exist such as unidentified palliative care needs and suboptimal collaboration between care settings. The aim of this study was to determine the feasibility of a TCP, named PalliSupport, for older patients at the end of life, prior to a stepped-wedge randomized controlled trial.
Some older persons develop a persistent death wish without being severely ill, often referred to as “completed life” or “tiredness of life”. In the Netherlands and Belgium, the question whether these persons should have legal options for euthanasia or physician-assisted suicide (EAS) is intensely debated. Our main aim was to investigate the prevalence and characteristics of older adults with a persistent death wish without severe illness, as the lack of this knowledge is a crucial problem in de debate.
Background: Previous research suggested that there might be distinct patterns of functional decline in the last years of life depending on the condition leading to death, but the validity of these results and hence the explanatory value of the condition leading to death for late-life disability are uncertain.
Methods: A total of 636 decedents from a cohort of 754 community-living persons, 70+ years of age (Yale PEP Study) provided 33 700 monthly observations of self-/proxy-reported disability during the last 5 years of life. Nonlinear trajectories and short-term fluctuations of late-life disability by condition leading to death (cancer, organ failure, frailty, severe dementia, sudden death, other) were estimated with flexible mixed spline regression models.
Results: Disability trajectories at the end of life varied distinctively by the condition leading to death. Estimated disability trajectories among cancer deaths increased gradually up until about 6 months before death, after which a steep terminal decline set in. Among those with organ failure, frailty, and dementia, in contrast, disability was higher, increased more gradually, and there was no clear-cut terminal phase. Adding the condition leading to death to other known risk factors increased the amount of explained between-person variation in late-life disability from R2 = 0.35 to 0.49. Short-term fluctuations in disability were not specific for decedents with organ failure.
Conclusions: The condition leading to death is an important determinant of trajectories of late-life disability. These trajectories follow distinct patterns partially resembling a previously outlined theoretical typology.
BACKGROUND: Antimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined.
AIM: To evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention.
DESIGN: 18-item single-center cross-sectional survey.
SETTING/PARTICIPANTS: Inpatient medicine subspecialists in 2018.
RESULTS: Of 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization (n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care (n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers (n = 64/67, 96%). Fifty-one percent (n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training.
CONCLUSIONS: Although the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.
BACKGROUND: Many patients receive unwanted, low-value, high-intensity care at the end of life because of poor communication with health care providers. Our aim was to evaluate the feasibility of using a physician assistant and an electronic tool to facilitate discussions about goals of care.
METHOD: We conducted a pilot study for the intervention (physician assistant-led discussion using an electronic tool) from Apr. 1 to Aug. 31, 2019. Patients aged 79 years or older admitted to the Royal Victoria Hospital (Barrie, Ontario) with either (i) no documented resuscitation preferences or (ii) a request for life-sustaining treatments in the event of a life-threatening illness were eligible for the intervention. The goal of this study was to complete more than 30 interventions. The primary outcomes included the proportion of consenting eligible patients, the time required and the proportion of patients changing their resuscitation preferences.
RESULTS: A total of 763 patients met the inclusion criteria, with 337 eligible for the intervention. Of these, 49 cases were contacted for consent, and 37 interventions were completed (75.5%, 95% confidence interval [CI] 61.1%-86.6%). On average, the intervention required 50 minutes (standard deviation 21) to complete. Overall, 31 interventions resulted in a change in resuscitation preferences (83.7%, 95% CI 68.0%-93.8%), with 22 patients choosing to forgo any access to life-sustaining treatments in the event of a life-threatening illness (59.4%, 95% CI 42.1%-75.2%).
INTERPRETATION: In this pilot study, the intervention was completed in a minority of eligible patients and required substantial time; however, it led to many changes in resuscitation preferences. Before designing a study to evaluate its impact, the intervention needs to be revised to make it more efficient to administer.
Background: Portable Orders for Life-Sustaining Treatment (POLST) are increasingly utilized to assist patients approaching the end of life in documenting goals of care. We evaluated the association of POLST, resource utilization, and costs to 1 year among injured older adults requiring emergency services.
Methods: This was a retrospective cohort of injured older adults =65 years with continuous Medicare fee-for-service coverage transported by emergency medical services (EMS) in 2011 across 4 counties in Oregon. Data sources included EMS, Medicare claims, vital statistics, and state POLST, inpatient and trauma registries. Outcomes included hospital admission, receipt of aggressive medical interventions, costs, and hospice use. We matched patients on patient characteristics and comorbidities to control for bias.
Results: We included 2116 patients of which 484 (22.9%) had a POLST form prior to 911 contact. Of POLST patients, 136 (28.1%) had orders for full treatment, 194 (40.1%) for limited interventions, and 154 (31.8%) for comfort measures. There were no significant associations for care during the index event. However, in the year after the index event, patients with care limitations had higher adjusted hospice use (limited interventions OR 1.7 [95% CI: 1.2–2.6]; comfort OR, 2.0 [95% CI: 1.3–3.0]) and lower adjusted post-discharge costs (no POLST, $32,399 [95% CI: 30,041–34,756]; limited interventions, $18,729 [95% CI: 12,913–24,545]; and comfort $15,593 [95% CI: 12,091–19,095]). There were no significant associations for all other outcomes.
Conclusions: Care limitations specified in POLST forms among injured older adults transported by EMS are associated with increased use of hospice and decreased costs to 1 year.
In Japan, many adults prefer to die at home; however, few have their preferences actually come true. While discussions regarding place of death preferences (DPDPs) are important for older adults, they are poorly documented. Therefore, we investigated the factors associated with older Japanese men and women having DPDPs. We used cross-sectional survey data collected for the Japan Gerontological Evaluation Study (JAGES). We applied multivariable logistic regression analysis to calculate the odds ratio (ORs) of having DPDPs separately between men (n = 2,770) and women (n = 3,038) aged = 75 years. We considered 17 potential factors associated with having DPDPs, which were classified as either demographic, healthcare, family, or community factors. Among participants, 50.1% had DPDPs: 1,288 men (44.3%) and 1,619 women (55.7%). Older adults, DPDPs were associated with 5 additional factors; e.g. having a primary care physician (ORs = 1.47 [men] and 1.45 [women]), as were those who gave family and friends advice (ORs = 1.26 [men] and 1.62 [women]), and having people who listened to their concerns (ORs = 1.70 [men] and 1.81 [women]). Among men, DPDPs were associated with 3 additional factors; e.g. humorous conversations with their spouse (OR = 1.60). Among women, only one factor—reading newspapers (OR = 1.43) was associated with having DPDPs. Social networks with primary care physicians, family members, and friends may be important factors in promoting DPDPs. These gender-based differences in older adults relating to DPDPs should be considered when developing interventions to promote advance care planning that includes DPDPs.
La pandémie à COVID-19 touche particulièrement les personnes les plus âgées et expose à un risque de mortalité les plus fragiles. Des mesures de confinement, de distanciation sociale et d’isolement ont été mises en place pour limiter la propagation virale. S’il existe un rationnel clair pour réduire la contagiosité de l’infection par ce biais, les conséquences néfastes de cet isolement social, en particulier pour cette population hétérogène, âgée et fragile sont difficiles à appréhender. En particulier, la rupture avec les structures habituelles de support et de soutien à domicile ou en institution, mais aussi le risque d’une diminution de « l’empowerment » de la personne âgée par rapport à ses propres décisions de santé et de vie sociale, imposent une vigilance particulière pour éviter un risque d’âgisme sociétal. Il peut ainsi exister, en regard de cette population particulière, des conflits de valeurs entre protection individuelle et collective, d’une part, et respect de l’autonomie et de l’indépendance, d’autre part. Cet article propose une réflexion éthique de la question du confinement des personnes âgées à risque de fragilités, s’appuyant sur des principes de l’éthique médicale, pour ouvrir les pistes de réflexion qui permettent une approche positive de la vulnérabilité, garante du respect de la dignité de la personne et de l’équité dans l’accès aux soins.