In a Crisis

We cannot predict every future health care decision that you will have to make, but in a crisis situation the following questions will help you make the choices that best represent your values and what you most want for yourself and your family.

1. Which health conditions are easily treatable? Which are not?


2. How will frailty make treatment risky?

Frailty describes a state of vulnerability. As people age they accumulate health problems and gradually become more frail. A person’s level of frailty has a major impact on how well they do with medical and surgical treatments. Frailty increases the risk of any treatment. You need to know how a proposed treatment will affect overall health and quality of life.

3. How can symptoms be safely and effectively managed?

Symptoms are the noticeable ways that disease affects us. Sometimes treating symptoms can lead to unwanted side effects. For example, treating pain can cause sedation or falls. Whether the risk of side effects is acceptable depends on the degree of suffering.

4. Will the proposed treatment improve or worsen function or memory?

Memory and function can both be seriously and permanently affected by surgery, certain drugs, and any time in hospital, especially if the person has dementia.

Memory: People with dementia commonly develop delirium in the hospital, which makes their memory worse. New research shows that the memory changes that occur with delirium may not go away. Such memory changes can be dramatic and worsen quality of life.

Dementia and delirium make the hospital experience more challenging. Due to confusion it is difficult for people with dementia and delirium to speak for themselves. They may be in pain, but not know how to call for a nurse to ask for help.

Function and mobility: Frail people who spend time in a hospital bed lose muscle strength almost immediately. This can make it hard for them to walk and perform the tasks of daily living. Here too, the changes that occur are not always reversible.

5. Will the proposed treatment require time in hospital?  If so, for how long?

Spending time in hospital can have lasting negative effects on frail people. Hospitalization can lead to infections, loss of strength and mobility, and worsening function and memory. The longer the stay, the worse the impact may be. To avoid these negative affects try to make the hospital experience easier, or consider forgoing hospital-based treatments in favour of controlling symptoms at home.

6. Will the treatment allow more good quality years, especially at home?

New health problems can have a major impact on life expectancy and quality of life. Make sure your health care providers understand current illnesses and what life expectancy was before the new problem emerged. This will help them tell you how the proposed treatment could affect the length and quality of you or your family member’s life.

It is important for you, your family and you health care providers to reflect on the overall goals of medical investigations, treatments, and surgery. Prolonging good quality of life is an important goal. If the treatment will not result in more good quality years, you may not want to accept it. You need to consider not only the risks of the treatment itself, but the risks of time in hospital. Deterioration in function, mobility and memory make make it difficult to return home. Following hospitalization, many older adults with multiple medical problems need to move into a nursing home. Or, they return home but require more help from a caregiver. Take these possibilities into account as you consider the proposed treatment.

7. What can we do to promote comfort and dignity in the time left?

If the decline in overall health cannot be reversed, it is up to you to let the medical team know your wishes. These may include requesting that comfort and dignity become top priority. At this point, it is important to find a non-invasive way to manage the most troublesome symptoms to minimize pain and discomfort. You may want to discuss ways to stay out of hospital during this time.