KEN HILLMAN. Ageing and end of life issues.

It is well known that our population is living longer. But has our health system adapted to this ageing population? Do the elderly fit into the construct of a single diagnosis? Can we identify those who are coming to the end of their life? Do we ask them if they would prefer to spend the last few months of life in hospitals? What is the impact of the increasing number of medications that they are taking? What is the impact of modern medicine on age related deterioration?

The practice and teaching of medicine remains based on younger patients with a single diagnosis. We take a history, perform a physical examination, do a few tests and bingo, there it is. The more obscure the diagnosis, the more it becomes the stuff of legends. However, most of our elderly patients do not have a single diagnosis.

As a routine, we have to assign a diagnostic label when the elderly are admitted to hospital. A respiratory tract infection or a fall may be the reason for the admission but the real problem is the accumulation of the predicable and age-related deterioration of people as we become older. The sum of these conditions has not, as yet, a diagnostic name or number. Instead, we reduce the patient’s condition to a series of so-called co-morbidities or chronic conditions.

The immediate reason for admission to hospital (the ‘diagnosis’) of an elderly person who may be bed bound and severely demented is currently paramount. Let’s say they have pneumonia. This becomes the focus of management, not the underlying chronic state of the patient who may be in the last few weeks of life. Pneumonia used to be called the old person’s friend. It was a painless and relatively comfortable way to die in someone who is coming to the last few weeks of life. Now this patient would be admitted to hospital and aggressively treated with antibiotics, intravenous fluids and perhaps, even more complex interventions in an intensive care unit, often without discussing other options with the patient.

As a result of the diagnostic imperative we have divided ourselves into specialties, based on individual organs or diseases. The life of emergency physicians is made miserable by trying to decide which of the many organ dysfunctions in an elderly patient is the most dominant. When the patient is finally admitted under a specialist, others are consulted in order to advise on the myriad of ‘medical’ problems that the elderly invariably have. The result is management by committee with little progress in addressing the real issues confronting the elderly patient, most of which are, in fact, not medical.

As well as being more important to the patient, their functional status is a greater determinant of health and prognosis than their underlying chronic medical conditions. The term frailty is being increasingly used to describe the functional state and various scales have been proposed to quantify it.

Frailty describes health from the patient’s perspective, more than the chronic medical conditions increasingly assigned to people as they age. As the elderly person approaches the end-of-life, they are confined to a conventional health system that has not adapted to this new population.

The fall back position for most elderly people near the end-of-life is admission to an acute hospital. At least two thirds of those at the end-of-life will be admitted to hospitals despite the fact that the majority would prefer to be managed in their own homes. In hospital, they are managed by specialist doctors who are programed to make you better. This is the strength of the medical system but it can also expose some weaknesses.

For example, one third of all emergency calls to patients in hospital are for patients not previously recognised as being at the end of life. The implications of this are significant. Because patients are not recognised at being at the end of life, they are subject to a vast array of ‘medical miracles’ in a futile attempt to keep them alive. This is sobering, both for the patient and their loved ones who haven’t been informed of their prognosis. Many may, given the choice, opt for a different way to spend their last few weeks or months of life. Moreover, prolonging life in this way is arguably the major contributor to the unsustainable costs of health care.

The elderly have their ‘illness’ addressed by well-meaning specialists who try to improve the function of their part of the body without standing back and taking in the whole picture. Even when recognised, medical specialists, are not necessarily trained, nor comfortable with having an honest and empathetic discussion with the patient and their carers.

Dying in the elderly has become medicalised, when many would prefer an honest explanation about their prognosis. Of course, uncertainty would also have to be explained, just as it is with any other condition where modern medicine has little or nothing more to offer. This doesn’t mean that care ceases. But ‘care’ could take the form of a greater variety of options for support in the community in ways consistent with patient preferences. This requires new thinking about resourcing for a new population of patients that doesn’t fit in with the way medicine is currently taught and practised.

Ken Hillman AO is Professor of Intensive Care, Liverpool Hospital, UNSW (SWS Clinical School), Director of The Simpson Centre for Health Services Research UNSW, Ingham Institute for Applied Medical Research. 

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