A New Approach

Why do we need a new approach?

As recently as the 1950s, many people with terminal cancer were not informed about their prognosis. Pain medication was withheld, and individuals routinely died after much suffering. In retrospect, this philosophy appears inhumane and out of step with modern medical values. However, if we compare the pre-palliative death-denying culture of the 1950s to today’s treatment standards for frail older adults, there are striking similarities.

Currently, health professionals may not recognize the clinical trajectory of terminal frailty. Likewise, patients and their families are not always informed about the limited life expectancy associated with co-existing, multiple, interacting, complex illnesses. As a result, patients and their families may overestimate life expectancy and may not recognize the benefits of a palliative approach. Medical decisions about burdensome and expensive interventions are often made without fully understanding the risk and limited effectiveness of these types of invasive procedures in the context of terminal frailty. Consequently, due to inadequate preparation for death, many frail older adults die in pain and isolation.

How does PATH add to existing health care programs?

If we look to the evolution of cancer care as a model, we find influential individuals, such as Dame Cicely Saunders and other palliative pioneers, who challenged established routines in favour of care plans that provided patients and their families with an understanding of their condition and the opportunity to die with dignity. A similar careful reevaluation of principles is now needed for the very frail elderly.

To develop an effective program that suits the needs of the frail, traditional palliative care need to be modified to embrace important differences between younger and older individuals. Cancer patients typically have predominant single-system disease. In contrast, the majority of frail older adults suffer from complex, interacting medical illnesses. This complexity requires a specialized evaluation and perceptive treatment paradigms. On one hand, medical management and treatment may improve health, but treatment without recognition of arrival at the end-of-life may cause undue adverse effects, harm and suffering.