Psychiatric Times.
No. 14
GERIATRIC PSYCHIATRY
End-of-Life Care and the Elderly
Special Considerations
By Harvey M. Chochinov, MD, PhD |
December 1, 2008
Dr. Chochinov is professor of psychiatry and Canada Research Chair in Palliative Care, University of Manitoba, and director of the Manitoba Palliative Care Research Unit, CancerCare Manitoba, both in Winnipeg. He reports no conflicts of interest concerning the subject matter of this article.
In an initial pilot study of 100 terminally ill, mostly elderly patients, 91% reported feeling satisfied with the experience, 81% found it helpful for their family, 76% said that it heightened their own sense of dignity, 68% reported an increased sense of purpose, and 67% reported a improved sense of meaning. Symptoms of depression and suffering were also reduced.35
CASE VIGNETTE
Based on Professor M’s predominant depressed mood and loss of interest in most activities, along with a certain element of self-deprecation, a trial of psychostimulant medication was initiated. These medications have a fast onset of action and are often energizing, making them particularly appropriate in the context of end-of-life care.36 The patient, in consultation with his family, was also offered a trial of dignity therapy. This gave him the opportunity to speak about his previous scholarly passions and life achievements and to engage, to a lesser extent, in some life review. For the time he was well enough to participate, this approach seemed to engender a sense of meaning and purpose. When the final “generativity document” was read in its entirety (a standard part the dignity therapy protocol), he and his wife thought that it had “captured his essence.”
Dignity-conserving care
Patients approaching death anticipate the loss of all they know and love. For the elderly, this can be marked by a shattered sense of self. The “ABCDs” of dignity-conserving care, namely attitude, behaviors, compassion, and dialogue, provide a framework that embraces core values of medical professionalism, such as humanity, kindness, and respect.37 For all patients, particularly the frail elderly, the application of this framework as a means of staving off end-of-life distress can complement any treatment.
Attitude emphasizes the notion that our view of the patient influences the way he sees himself. Patients look to their care provider for affirmation or acknowledgment of continued worth. People near the end of life, the young as well as the old, maintain the wish to be seen in terms of who they are or who they once were.
Behaviors refers to how health care providers interact with patients. Even small cues, such as not being fully attentive or assuming one knows how the patient wishes to be addressed, can further assault a patient’s sense of self. All behavior toward the elderly patient should be predicated on understanding that patients need to feel accepted as human beings and individuals, not just as objects of medical interventions.
Compassion refers to a deep awareness of the suffering of another, coupled with the wish to relieve it. Compassion begins with the humble realization that each and every one of us is vulnerable. In caring for the elderly, it is especially important not to lose touch with the fact that, death notwithstanding, aging and disability are inevitable. A not-so-subtle reminder of this comes from the disability community, where the term “TAB” is often used to refer to the Temporarily Able-Bodied.
Dialogue underscores the importance of conversations that acknowledge personhood. It can be as simple as finding out who the patient is, or asking what needs to be known to deliver the best care possible.
In palliative care, novel psychotherapeutic approaches based on existential themes such as meaning, purpose, and dignity are showing great promise in their ability to diminish suffering and enhance the will to live. Perhaps being mindful of these issues in the context of providing care to the elderly could yield similar results.
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Evidence-Based References
Burt J, Raine R.The effect of age on referral to and use of specialist palliative care services in adult cancer patients: a systematic review. Age Ageing. 2006;35: 469-476.
Tornstam L. Caring for the elderly: introducing the theory of gerotranscendence as a supplementary frame of reference for caring for the elderly. Scand J Caring Sci. 1996;10:144-150.
