Medical care for the final years of life: "When you're 83, it's not going to be 20 years"

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.

Figure 1

Possible future functional and health status trajectories for Mr Z. Trajectory A assumes good health and gradual functional decline with Mr Z living twice the median survival for 85-year old US men. Trajectory B assumes that he develops a chronic degenerative disease (eg, Alzheimer disease, Parkinson's disease) and experiences steady functional decline with a period of prolonged functional dependency and the expected length of survival. Trajectory C assumes a sudden catastrophic event (eg, hip fracture, stroke) with some functional improvement but without return to baseline and a shorter than expected life.