Medical

The Relationship between Age and Treatment of Adults

Historically, at “the end of life”, the older adult has been treated in many different ways, from the unusually cruel, to the exceptionally caring, to the equivocally equivocal. For instance, in some cultures:

“. . .the Ligurians, of Southern Gaul, routinely threw their parents, whenever they were no longer useful because of old age, off of a cliff. . .,”

“From Procopius, we learn of the eugenic practices of the Heruli, a Germanic tribe, who assembled their sick and elderly in woodpiles, [‘mercifully’] stabbing them to death before setting the piles alight.. . . .,”

“The Liverpool Care Pathway was infamous in recent times as a method of speeding up death in particular for elderly people by denying them hydration. . . . ,[and]”

“. . .if the Icelandic sagas are any indication, they would have lived as part of a larger family unit and been cared for by members of their immediate family. In-home care, it seems, was the only option at the time. . .”

Today, if during an “end-of-life” discussion, your physician recommended throwing your grandmother off of the cliff, stabbing her to death, denying her hydration, or following the tradition outlined in an Icelandic saga, how would you respond to such suggestions? Would you be impressed by his/her tactful use of medical communication in guiding these sensitive discussions or would you be taken aback? Most loved ones of patients who are recovering from a serious illness expect the best of such discussions from their physicians. However, is this always possible during the very busy and demanding reality of the outpatient or inpatient clinical setting? Do we, as physicians and other healthcare providers allow the health care practice norms, institutional standards, and other ‘norms” to truncate our efforts to provide the best decision making in these complicated clinical scenarios, for instance, for those with colon cancer? Particularly, when the clinical evidence guiding such decision-making may be limited or non-existent? Do we even consider utilizing our sociological perspective or clinical gestalt? Do we take into account how a patient’s cultural practices related to “end-of-life” may positively or negatively impact our clinical decision-making? Is there a better way to communicate life expectancy, so that the provider, patient, patient’s loved ones, and other healthcare providers may make the best possible decisions regarding the patient’s health and well-being?

For example, suppose your grandmother, who was a previously healthy 65-year-old, develops end-stage renal disease, is placed on dialysis, and dies prematurely. Historically, we know that patients on dialysis that if, in the same scenario, the physician, using a life expectancy calculator, had determined that, before dialysis, your grandmother’s life expectancy was 70 years with her known medical conditions, and with dialysis, 75 years. And, that this tool and its application as one that was accepted by the general medical community and the hospital protocol, how might this have made a difference in her medical care and the medical care of others like her? If physicians and hospitals knew that such a tool could potentially make a major difference in the patient’s life and in health care outcomes, would they do a better job? Would patients and families feel more comfortable with their physicians and the healthcare institution?

Blue Zones, an organization whose goal is to help people live longer, developed a tool that can potentially do the aforementioned. The True Vitality Test is a tool that measures several factors including demographics, morbidity, mental outlook, environment, diet, and physical activity. The resultant calculation can help determine a person’s life expectancy. In addition to providing information that assists clinicians in determining which interventions would potentially extend the length and quality-of-life for older adult patients, life-expectancy calculators may also be useful in preventing the use of interventions, or screenings that are unlikely to benefit—or could even harm—the older adult chronically ill patients.

Several guidelines recommend including life-expectancy in clinical decision-making for preventive interventions, especially in vulnerable patients. Although incorporating an assessment of life expectancy in geriatric practice has the potential to effectively help physicians with accurate medical decision-making, very few practitioners implement the use of such tools in everyday practice. Several tools implicate the importance of life-expectancy measurements. Effective decision-making is essential when generating new evidence and ideas to facilitate geriatric care goals, including increased quality, improved outcomes, and reduced costs. Assessment of literature informs physicians, and other health professionals about new health practices, valuable interventions, variations in the geriatric workforce, health outcome optimization strategies, training practices, how to increase the provider to patient ratios, and how to successfully address barriers to tackle current issues affecting aging communities throughout the nation.

As such tools do exist, might we improve the health outcomes of older adults through a logical and well-thought-out process of informed medical decision-making? As stated in the Institute of Medicines’ Report, “To Err is Human,” however, might we reduce human error with well thought out medical decision-making? Taking into account the sociological, holistic, and other environmental factors that affect a patient’s life expectancy, including the utilization of appropriate evidence-based tools, is a critical component of such tools.

As older adults make important decisions about their future: retirement, relocating, moving in with family, transitioning to a nursing home or an assisted living facility, an individualized estimate of the number of healthy years remaining could help with several decisions, perhaps spark a sense of relief for some. Might healthcare providers provide better medical care, improved communication surrounding end-of-life decision making, and life-expectancy estimates, including during horizontal, and vertical transitions-in-care if our progress notes read something like this:

65-year-old woman, former school bus driver, with a past medical history of chronic obstructive pulmonary disease, on two liters of home oxygen, with chronic kidney disease, with a pre-dialysis life-expectancy of 5-years, and post-dialysis life-expectancy of 10-years based off of “x” life-expectancy calculator, who was started on hemodialysis during this admission, and is now ready for transfer to a skilled nursing facility; the following plan has been instituted which may positively or negatively impact the patient’s life-expectancy +/- x years, based off of the following findings, utilizing a biopsychosocial/global/holistic perspective. The physician, and/or care team has taken the following steps to mitigate any decrease in life expectancy, improve, or reduce the reduction in life expectancy and maintain or improve the patient’s quality of life. This has included a discussion with the hospital ethics committee (if warranted), patient, family members, transferring team, and receiving facility if indicated.

Physicians should avoid cultural norms and practices that encourage the premature death of a patient when life expectancy estimates have not been obtained. Geriatricians are in a unique role to influence this discussion, including researching ways to provide enhanced healthcare through improved end-of-life decision making, by developing, and utilizing such tools as the True Vitality Age calculator.

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Samuel K. Williams, III, M.D., C.P.G., Ashruta Patel, MS, DO, and Allison Doyle, MPH, Tiffany R. Groover, MPH, MD Samuel K. Williams, III, M.D., C.P.G., Ashruta Patel, MS, DO, and Allison Doyle, MPH, Tiffany R. Groover, MPH, MD