As the median age of practicing physicians increases, ethical dilemmas due to age-related cognitive decline among clinicians will become ever more pressing. Compelling data show that despite acknowledgement of their duty to protect the public, physicians often fail to report themselves, their colleagues, or their physician-patients when cognitive decline appears to impact medical practice adversely. As such, efforts to educate physicians about ethical obligations and various tactful methodologies to report themselves or others seem ineffective. Illustrated by a case report of age-related cognitive decline in a practicing physician, practical recommendations are made both to develop and validate cognitive screening in middle-aged physicians, presumably before the onset of age-related cognitive decline.
BACKGROUND: There is a heterogeneous literature on healthcare utilization patterns at the end of life. The objective of this study is to examine the impact of closeness to death on the utilization of acute hospital-based healthcare services and some primary healthcare services and compare differences in gender, age groups and major causes of death disease specific mortality.
METHODS: A matched case-control study, nested in a cohort of 411,812 subjects, linked to administrative databases was conducted. All subjects were residents in the Friuli Venezia Giulia Region (Italy), born before 1946, alive in January 2000 and were followed up to December 2014. Overall, 158,571 decedents/cases were matched by gender and year of birth to one control, alive at least one year after their matched case's death (index-date). Hospital admissions, emergency department visits, drug prescriptions, specialist visits and laboratory tests that occurred 365 days before death/index-date, have been evaluated. Odds Ratios (ORs) for healthcare utilization were estimated through conditional regression models, further adjusted for Charlson Comorbidity Index and stratified by gender, age groups and major causes of death.
RESULTS: Decedents were significantly more likely of having at least one hospital admission (OR 7.0, 6.9-7.1), emergency department visit (OR 5.2, 5.1-5.3), drug prescription (OR 2.8, 2.7-2.9), specialist visit (OR 1.4, 1.4-1.4) and laboratory test (OR 2.7, 2.6-2.7) than their matched surviving counterparts. The ORs were generally lower in the oldest age group (95+) than in the youngest (55-74). Healthcare utilization did not vary by sex, but was higher in subjects who died of cancer.
CONCLUSION: Closeness to death appeared to be strongly associated with healthcare utilization in adult/elderly subjects. The risk seems to be greater among younger age groups than older ones, especially for acute based services. Reducing acute healthcare at the EOL represents an important issue to improve the quality of life in proximity to death.
Palliative care research has largely focused on patients with disease specific conditions such as advanced cancer, cardiac or pulmonary diseases. As patients age, however, they often develop chronic conditions that may lead to decreases in health-related quality of life or symptoms such as pain and dyspnea. As the population ages, the prevalence of patients with multi-morbidity also increases but these patients may not be identified as having palliative care needs.
En 2017, 606 000 personnes sont décédées en France. La moitié avait plus de 83 ans et un quart plus de 90 ans. L'âge moyen au décès ne cesse d'augmenter depuis cinquante ans. Il est passé de 72 ans pour les femmes décédées en 1967 à 83 ans pour celles décédées en 2017, et de 64 à 76 ans pour les hommes sur la même période. Depuis 1967, le nombre de décès de nouveau-nés a été divisé par six.
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Despite education and professional preparation, age and diagnosis discrimination persists in health care. A case scenario describes discrimination that could have resulted in untimely death without advocacy and intervention by 1 informed professional. Nurses must identify their own attitudes and behaviors associated with age, diagnosis, and their role within the interprofessional team to identify when discrimination may be occurring and claim their responsibility as advocate to ethically intervene on behalf of patients and families when appropriate.
OBJECTIVES: To explore how psychology trainee death concerns and ageist behavior relate to their willingness and desire to work with older adults.
METHOD: Trainees (N = 104; 80.8% women) completed the Death Thought-Accessibility Measure, Relating to Older People Evaluation (ROPE), Death Anxiety Scale-Extended (DASE), and Beck Anxiety Inventory (BAI) and rated their willingness and desire to work with older adults and their willingness to obtain training on how to work with older adults.
RESULTS: Pearson correlations showed that salience of death-related thoughts, death anxiety (but not general anxiety), and negative behaviors toward older adults were significantly negatively associated with trainees' willingness and desire to work with older adults. Regressions revealed that negative behaviors toward older adults was the strongest factor associated with willingness and desire to work with older adults, whereas positive behaviors toward older adults was the strongest factor associated with being willing to obtain training in working with older adults. Death anxiety and salience of death-related thoughts positively correlated with each other and were each positively associated with negative behaviors toward older adults.
CONCLUSION: Helping graduate trainees become more comfortable with mortality and changing negative behaviors toward older adults may increase their interest in gerontology and geriatrics.
Long-term care (LTC) planning is important in helping the older people tackle their future needs better. The needs for LTC services represent generational characteristics as they may be different between the current and upcoming cohorts of older adults. However, very few studies have examined the cohort differences in terms of their expected utilisation of LTC services, while understanding the patterns is crucial in helping policy makers prepare for the development of LTC services. This study fills the research gap by examining the plans and expectations for LTC services of 1,613 middle-aged and older persons in Hong Kong with data collected from a telephone survey. By applying the Andersen Model to examine LTC expectations, this study analyses the LTC needs and plans of the middle-aged and older cohorts of Hong Kong adults, as well as their associated factors, with a multiple logistic regression method. Both gender and birth cohort were examined individually and in combination. Birth cohort and gender have been found to exert an impact on all aspects of LTC needs and planning to varying degrees. The findings are interpreted and contrasted with those of a key study based in the West, with reference to the contextual characteristics of Hong Kong. This study furthers the scholarly understanding on LTC needs and planning and their cohort effect, and draws evidence-based recommendations for LTC development in Hong Kong, a rapidly ageing East Asian society.
OBJECTIVES: Although a national consensus exists on the need to increase the rates of advance care planning (ACP) for all adults, racial/ethnic differences in ACP have been consistently observed. This study investigated the intersection of racial/ethnic differences and the number of chronic health conditions on ACP among middle-aged and older adults in the United States.
METHOD: Responses from 8,926 adults from the 2014 wave of the Health and Retirement Study were entered into multilevel hierarchical logistic regression analyses with generalized linear mixed models to predict ACP focused on assigning a durable power of attorney for healthcare (DPOAHC) and having a written living will after adjusting for covariates.
RESULTS: We found a significant positive relationship between the number of chronic health conditions and ACP. Non-Hispanic Blacks/African Americans and Hispanics were less likely to engage in ACP than non-Hispanic Whites/Caucasians. Racial/ethnic disparities were even starker for completing a living will. The number of chronic health conditions had a greater effect for Hispanics than non-Hispanic Whites/Caucasians on ACP through assigning a DPOAHC and having a living will. The initial disparity in ACP among Hispanics with no chronic health conditions decreased as the number of chronic health conditions increased.
CONCLUSION: Our findings suggest that more chronic health conditions increase the likelihood that Hispanics will complete ACP documents. These ACP differences should be highlighted to researchers, policymakers, and healthcare professionals to reduce stark racial/ethnic disparities in ACP. A comprehensive and culturally caring decision-making approach should be considered when individuals and families engage in ACP.
The goal of the current study was to explore how age-of-death (AOD) and mode-of-death MOD simultaneously influence ratings of sympathy, empathy, and tragedy toward the deceased in order to assess social value. Three hundred and fifty-eight participants, mainly undergraduates, responded to a series of vignettes that described a MOD (suicide, accident, or stroke) counterbalanced with three AODs (younger, middle-aged, and older). Overall, ratings of sympathy, empathy, and tragedy declined as AOD increased; however, the effect of AOD was not consistent across all MODs. The pattern of results suggests that death norms and perceived control of death impact the perception of the deceased.
This study aimed to elicit the attitudes and beliefs of middle-aged and elderly Moroccan Muslim women regarding mourning and remembrance, to identify whether differences are observable between middle-aged and elderly participants, to explore the role of religion and to document how the actual attitudes of our participants relate to normative Islamic literature. Interviews were conducted with middle-aged and elderly Moroccan women living in Belgium (n = 30) and with experts in the field (n = 15). This study reveals that the religious beliefs have a great impact on the views of Muslim women. We found striking similarities between our participants’ views and normative Islamic literature.
En France, la question de l'euthanasie divise encore l'opinion publique. Ce livre viendra donc utilement éclairer le débat. En effet, en Belgique, l'euthanasie a été dépénalisée en 2002. Elle est dorénavant considérée comme un acte de soins, pratiqué - exclusivement - par un médecin, à condition que le malade en fasse la demande expresse et répétée. Concrètement comment cela se passe-t-il ? Quelles sont les démarches à effectuer ? Quel est le rôle du médecin ? Et la famille dans tout ça ? Et les soins palliatifs ? L'auteur, médecin engagé dans la pratique de l'euthanasie depuis plus de dix ans, nous livre ici tant un état des lieux documenté, enrichi de cas concrets, qu'un témoignage nuancé et sincère.
[Quatrième de couverture]
Adding to recent evidence of terminal decline in affective well-being, this study examined the role of physical health in accounting for time-to-death-related changes in positive affect (PA) and negative affect (NA). We distinguished effects of preterminal health levels predicting levels ("preserved differentiation") and terminal changes ("differential preservation") and of terminal health declines predicting terminal changes ("terminal reactivity") of affective well-being in the terminal period of life. Data were used from the first cohort of the Longitudinal Aging Study Amsterdam, including 3-yearly measurements from 1992-1993 to 2011-2012 (N = 2310, age = 55-85 at baseline). Measures of PA and NA were derived from the Center for Epidemiologic Studies Depression Scale. Health measures included self-rated health, self-reported functional limitations, and gait speed. Exponential time-to-death-related trajectories in PA and NA were analyzed with mixed regression models. Results confirmed accelerated time-to-death-related decline of PA and increase of NA. Regarding health effects, the findings support terminal reactivity, in that the amount of end-of-life changes in affective well-being was closely linked to the concurrent terminal changes in health. Preterminal health levels did not predict the amount of terminal changes in affective well-being; however, reaching the final years of life with better levels of functional health appeared to promote longer maintenance of better levels of affective well-being and terminal declines more "compressed" to a shorter period prior to death. The findings point to needs to strengthen individuals' resources to compensate for health losses at the end of their life span.
We use two historical data sources - the Health and Retirement Study and the Medicare Current Beneficiary Study - to consider the patterns in older Americans' severe disability and their use of long-term services and supports (LTSS) by age and socioeconomic status. We then use a dynamic microsimulation model to project how the effects of various interventions to support those with severe disabilities and their caregivers would be distributed across the income distribution. The interventions that we examine fall into three broad classes : tax credits for caregiving expenses, respite care for people in the community with family caregivers, and new social insurance programs. Within each broad class of policies, we examine how sensitive outcomes are to changes in policy details (such as, in the case of tax credits, deductible levels, refundability, and income phase-outs).
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OBJECTIVES: The effects of socio-demographic and economic factors on institutional long-term care (LTC) among people with dementia remain unclear. Inconsistent findings may relate to time-varying effects of these factors as dementia progresses. To clarify the question, we estimated institutional LTC trajectories by age, marital status and household income in the eight years preceding dementia-related and non-dementia-related deaths.
METHODS: We assessed a population-representative sample of Finnish men and women for institutional LTC over an eight-year period before death. Deaths related to dementia and all other causes at the age of 70+ in 2001-2007 were identified from the Death Register. Dates in institutional LTC were obtained from national care registers. We calculated the average and time-varying marginal effects of age, marital status and household income on the estimated probability of institutional LTC use, employing repeated-measures logistic regression models with generalised estimating equations (GEE).
RESULTS: The effects of age, marital status and household income on institutional LTC varied across the time before death, and the patterns differed between dementia-related and non-dementia-related deaths. Among people who died of dementia, being of older age, non-married and having a lower income predicted a higher probability of institutional LTC only until three to four years before death, after which the differences diminished or disappeared. Among women in particular, the probability of institutional LTC was nearly equal across age, marital status and income groups in the last year before dementia-related death. Among those who died from non-dementia-related causes, in contrast, the differences widened until death.
CONCLUSIONS: We show that individuals with dementia require intensive professional care at the end of life, regardless of their socio-demographic or economic resources. The results imply that the potential for extending community living for people with dementia is likely to be difficult through modification of their socio-demographic and economic environments.
INTRODUCTION: To evaluate whether age is a predictor of pain response after radiotherapy for painful bone metastasis (BM).
METHODS: Between June 2010 and June 2014, 204 patients with BM undergoing palliative radiotherapy participated in a multicentre prospective study. Patients completed the Brief Pain Inventory (BPI) to rate the intensity pain (from 0 to 10) at baseline and 4 weeks after radiotherapy. To determine which variables predicted pain response and particularly whether age is a predictor, logistic regression analysis was used. Baseline variables considered were: age (=65/66–75/>75 years), sex, Eastern Cooperative Oncology Group performance status (0–1/=2), pretreatment pain score (=4/5–7/=8), radiotherapy (single/multiple fraction), primary tumour location, visceral metastases (yes/no), concomitant systemic chemotherapy and bisphosphonate use (yes/no).
RESULTS: Pain response was assessed in the 128 patients who completed BPI pretreatment and at 4 weeks after radiotherapy. According to univariate analysis, pain response was better in over 75-year-olds than younger patients: (OR, 3.2; 95% CI, 1.1–9.1; P = 0.031). Response was better in patients receiving multiple fractions rather than a single fraction of 8 Gy (OR, 2.8; 95% CI, 1.2–6.1; P = 0.01), and in patients with a pretreatment pain score =8 vs =7 (OR, 2.4; 95% CI, 1.1–5.0; P = 0.017). No other variables were significant. Multivariate analysis showed that treatment schedule (OR, 3.4; 95% CI 1.4–7.9; P = 0.004) and pre-radiotherapy pain score (OR, 2.8; 95% CI 1.3–6.3; P = 0.009) were the only independent predictors of pain response.
CONCLUSION: All patients with painful bone metastasis should be referred for palliative radiotherapy to relieve the pain regardless of age. Therefore, an older age should not be a reason to withhold palliative radiation treatment.
OBJECTIVES: Both bereavement and thwarted belongingness serve as risk markers for youth suicide-related behaviors. This study examined candidate predictors of thwarted belongingness among bereaved youth, including caregiver cause of death and surviving caregiver coping style.
METHODS: Forty-three caregiver-bereaved families (58 children aged 7-13 years old) participated in a longitudinal study investigating associations between hypothesized bereavement-related contextual factors and youth thwarted belongingness. Cause of caregiver deaths included anticipated deaths preceded by illness (37%; n = 16), sudden natural deaths (25.6%; n = 11), accidental deaths (20.9%; n = 9), death by suicide (9.3%; n = 4), and death from drug overdose (7.0%; n = 3).
RESULTS: Children's thwarted belongingness was significantly higher among youth bereaved by suicide compared to youth bereaved by youth bereaved by sudden natural death, accident, and anticipated death by illness. Surviving caregivers' use of behavioral disengagement and positive reinterpretation and growth as coping strategies at Time 1 predicted lower thwarted belongingness in children at Time 2.
CONCLUSIONS: Implications for risk screening and assessment of suicide risk among bereaved youth are discussed.
BACKGROUND: In the last decade, the number of patients continuously deeply sedated until death increased up to fourfold. The reasons for this increase remain unclear.
OBJECTIVE: To identify socio-demographic and clinical characteristics of sedated patients, and concurrent possibly life-shortening medical end-of-life decisions.
DESIGN: Cross-sectional death certificate study in German-speaking Switzerland in 2001 and 2013.
PARTICIPANTS: Non-sudden and expected deaths (2001: N = 2281, 2013: N = 2256) based on a random sample of death certificates and followed by an anonymous survey on end-of-life practices among attending physicians.
MAIN MEASURES: Physicians' reported proportion of patients continuously deeply sedated until death, socio-demographic and clinical characteristics, and possibly life-shortening medical end-of life decisions.
KEY RESULTS: In 2013, physicians sedated four times more patients continuously until death (6.7% in 2001; 24.5.5% in 2013). Four out of five sedated patients died in hospitals, outside specialized palliative care units, or in nursing homes. Sedation was more likely among patients younger than 65 (odds ratio 2.24, 95% CI 1.6 to 3.2) and those dying in specialized palliative care (OR 2.2, 95% CI 1.3 to 3.8) or in hospitals (1.7, 95% CI 1.3 to 2.3). Forgoing life-prolonging treatment with the explicit intention to hasten or not to postpone death combined with intensified alleviation of symptoms was very strongly associated with continuous deep sedation (OR 6.8, 95% CI 4.7 to 9.8).
CONCLUSIONS: In Swiss clinical practice, continuously deeply sedated patients predominantly died outside specialized palliative care. The increasing trend over time appears to be related to changes in medical end-of-life practice rather than to patient's clinical characteristics.
PURPOSE: The present study assesses the relationship between patient dignity in advanced cancer and the following variables: psychological distress, preparatory grief, and sociodemographic and clinical characteristics.
METHODS: The sample consisted of 120 patients with advanced cancer. The self-administered questionnaires were as follows: the Preparatory Grief in Advanced Cancer Patients (PGAC), the Patient Dignity Inventory-Greek (PDI-Gr), the Greek Schedule for Attitudes toward Hastened Death (G-SAHD), and the Greek version of the Hospital Anxiety and Depression Scale (G-HADS).
RESULTS: Moderate to strong statistically significant correlations were found between the 4 subscales of PDI-Gr (psychological distress, body image and role identity, self-esteem, and social support) with G-HADS, G-SAHD, and PGAC ( P < .005), while physical distress and dependency was moderately correlated with depression. Multifactorial analyses showed that preparatory grief, depression, and age influenced psychological distress, while preparatory grief, depression, and performance status influenced body image and role identity.
CONCLUSIONS: Preparatory grief, psychological distress, and physical symptoms had significant associations with perceptions of dignity among patients with advanced cancer. Clinicians should assess and attend to dignity-distressing factors in the care of patients with advanced cancer.
En 2016, 594 000 personnes sont décédées en France : 59% sont décédées dans un établissement de santé, 26% à domicile, 14% en maison de retraite et 1% sur la voie publique. À chaque âge, la plupart des décès ont lieu dans un établissement de santé. Toutefois, les disparités sont fortes selon l'âge. Entre 15 et 24 ans, un tiers des décès ont lieu sur la voie publique. Après 100 ans, la part des décès à domicile est la même qu'en maison de retraite (36%).
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BACKGROUND: Early palliative care interventions enhance patient outcomes, including quality of life, mood, and coping, but it remains unclear whether certain subgroups of patients are more likely to benefit from early palliative care. We explored whether age and sex moderate the improved outcomes seen with early palliative care.
METHODS: We performed a secondary analysis of data from a randomized trial of 350 patients with advanced lung and non-colorectal gastrointestinal cancer. Patients received an early palliative care intervention integrated with oncology care or usual oncology care alone. We used linear regression to determine if age (older or younger than 65) and sex moderated the effects of the intervention on quality of life (Functional Assessment of Cancer Therapy-General (FACT-G)), depression symptoms (Patient Health Questionnaire 9 (PHQ-9)), and coping (Brief COPE) within lung and gastrointestinal subgroups.
RESULTS: At 24 weeks, younger patients with lung cancer receiving early palliative care reported increased use of active coping (B = 1.74; p = 0.02) and decreased use of avoidant coping (B = â€“0.97; p = 0.02), but the effects of early palliative care on these outcomes were not significant for older patients. Male patients with lung cancer assigned to early palliative care reported better quality of life (FACT-G: B = 9.31; p = 0.01) and lower depression scores (PHQ-9: B = â€“2.82; p = 0.02), but the effects of early palliative care on these outcomes were not significant for female patients. At 24 weeks, we found no age or sex moderation effects within the gastrointestinal cancer subgroup.
CONCLUSION: Age and sex moderate the effects of early palliative care for patients with advanced lung cancer. Early palliative care may need to be tailored to individuals' unique sociodemographic and clinical characteristics.