Article

Medical Care for the Final Years of Life: “When You're 83, It's Not Going to Be 20 Years”

David Geffen School of Medicine at UCLA, Department of Medicine, Division of Geriatrics, 10945 Le Conte Ave, Ste 2339, Los Angeles, CA 90095-1687, USA.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 12/2009; 302(24):2686-94. DOI: 10.1001/jama.2009.1871
Source: PubMed

ABSTRACT

The case of an 83-year-old man who has had a fall-related injury and continues to be the sole caregiver for his wife who has dementia exemplifies a common situation that clinicians face--planning for the final years of an elderly individual's life. To appropriately focus on the patient's most pressing issues, the approach should begin with an assessment of life expectancy and incorporation of evidence-based care whenever possible. Short-term issues are focused on efforts to restore the patient to his previous state of health. Mid-range issues address providing preventive care, identifying geriatric syndromes, and helping him cope with the psychosocial needs of being a caregiver. Long-term issues relate to planning for his eventual decline and meeting his goals for the end of life. Unfortunately, the workload and inefficiencies of primary care practice present barriers to providing optimal care for older patients. Systematic approaches, including team care, are needed to adequately manage chronic diseases and coordinate care.

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Available from: geriatrics.medicine.arizona.edu
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    • "e l s e v i e r . c o m / l o c a t e / p a t e d u c o u situations for older patients with multi-morbidity, a goal-oriented approach towards shared decision-making is more advisable than the traditional disease-oriented and technology-focused approach [9] [10] [11] [12]. In a goal-oriented approach the focus lies on the patient's most pressing issues, rather than on the underlying diseases. "

    Full-text · Dataset · Jan 2016
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    • "A model was developed based on the model of Elwyn et al., the existing literature and the experiences of physicians in the field of elderly care, geriatrics and SDM [2] [6] [9] [10] [11] [14] [16] [21]. Physician experiences were gathered by a researcher (MvdP) through discussions with physicians (self-report of consultation behaviours). "
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    ABSTRACT: Objective: Shared decision-making (SDM) is widely recommended as a way to support patients in making healthcare choices. Due to an ageing population, the number of older patients will increase. Existing models for SDM are not sufficient for this patient group, due to their multi-morbidity, the lack of guidelines and evidence applicable to the numerous combinations of diseases. The aim of this study was to gain consensus on a model for SDM in frail older patients with multiple morbidities. Methods: We used a three-round Delphi study to reach consensus on a model for SDM in older patients with multiple morbidities. The expert panel consisted of 16 patients (round 1), and 59 professionals (rounds 1-3). In round 1, the SDM model was introduced, rounds 2 and 3 were used to validate the importance and feasibility of the SDM model. Results: Consensus for the proposed SDM model as a whole was achieved for both importance (91% panel agreement) and feasibility (76% panel agreement). Conclusions: SDM in older patients with multiple morbidities is a dynamic process. It requires a continuous counselling dialogue between professional and patient or proxy decision maker. Practice implications: The developed model for SDM in clinical practice may help professionals to apply SDM in the complex situation of the care for older patients.
    Full-text · Article · Dec 2015 · Patient Education and Counseling
    • "e l s e v i e r . c o m / l o c a t e / p a t e d u c o u situations for older patients with multi-morbidity, a goal-oriented approach towards shared decision-making is more advisable than the traditional disease-oriented and technology-focused approach [9] [10] [11] [12]. In a goal-oriented approach the focus lies on the patient's most pressing issues, rather than on the underlying diseases. "
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    ABSTRACT: Background: In recent years, primary health care for the ageing population has become increasingly complex. Aim: This study sought to explore the views and needs of healthcare professionals and older patients relating to primary care in order to identify focal areas for improving primary health care for older people. Design and setting: This research was structured as a mixed interview study with focus groups and individual interviews. Participants were made up of primary healthcare professionals and older patients. Patients were recruited from five elderly care homes in a small city in the southern part of the Netherlands. Method: All interviews were transcribed verbatim and analysed by two individual researchers applying constant comparative analysis. Data collection proceeded until saturation was reached. Results: Participants in the study agreed about the need for primary care for older patients, and showed sympathy with one another's perspectives. They did note, however, a number of obstacles hindering good healthcare provision. The major themes that arose were: 'autonomy and independence', 'organisational barriers', and 'professional expertise'. Participants generally noted that it is important to clarify differences in perspectives about good care between patients and healthcare professionals. Conclusion: Effective primary care intervention for older patients requires mutual understanding of the expectations and goals of all parties involved. There are a number of important requirements, especially accessible patient information in the form of care plans; specialist training for nurses and GPs on complex care and multimorbidity; and training on discussing autonomy, goal setting, and shared care. Further improvement in health care for older people and its evaluation research should focus on these requirements.
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