Palliative Care in Older Adults

A patient may leave hospice care if his condition improves and reenter if the condition worsens. The goal of hospice, consistent with palliative care, is to keep the patient’s pain and suffering to a minimum. Hospice care can be delivered at home or in a hospital, nursing home, or private hospice facility. Hospice can provide companionship, spiritual care, transferral of the patient from home care to inpatient care, respite care for caregivers, family conferences, after-death services, and bereavement care.

Because pain management and symptom control may be difficult with dementia, many patients are cared for in nursing homes. The final stage can last from months to years. Medicare allows hospice care for 2 periods of 90 days, followed by an unlimited number of 60-day periods, as long as the physician recertifies that the patient is not getting better and is still terminal. Patients remain eligible for hospice services if their decline is measurable (from month to month) and their prognosis can be recertified by their primary care physician. Ways to enhance hospice enrollment for patients with advanced dementia include:

• Educating nursing homes about the appropriate time to suggest hospice services

• Educating families and physicians that dementia is terminal and about the disease process

• Increasing the comfort of physicians to certify that a patient has 6 months (or less) to live, although some patients may actually live longer

• Identifying and controlling pain symptoms in cognitively impaired patients

Conclusion

The palliative approach described in this article is no less aggressive in hastening treatment outcome than that used in a curative treatment model. Indeed, the imperative for symptom reduction and enhanced quality of life may be more pressing given both the urgency (eg, pain) or the terminal nature (eg, end-stage dementia) of these conditions and the profound effect on families and caregivers.