Clinics in geriatric medicine
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Dementia is a common, devastating, and ultimately fatal illness. Although no cure exists for most causes of dementia, palliative interventions for the predictable complications of the illness can effectively reduce the suffering of patients and families. Care of patients with end-stage dementia is clinically and conceptually consistent with hospice and palliative care, and this approach to care for patients with terminal dementia is preferred. Although the 6-month risk for mortality can be predicted (to satisfy current American hospice eligibility requirements), palliative care interventions are appropriate much earlier in the course of deterioration from dementia.
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The benefits and risks for older adults with dementia executing advance directives are discussed. Salient issues related to decision-specific capacity and models for advance planning and end-of-life decisions by cognitively impaired older adults are presented.
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Clin. Geriatr. Med. · May 2000
Review Case ReportsTalking to the older adult about advance directives.
Discussing advance care plans with elderly patients can improve the experience of end-of-life care for patients, families, and health care teams. Specific goals for any particular discussion should be based on patients' particular clinical circumstances. Physicians should focus on patients' overall values and goals and should provide emotional support during the discussion. Decisions made during the advance care planning process should be documented.
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Delirium is highly prevalent in terminally ill patients, especially in the last weeks of life, when some cognitive impairment develops in as many as 85% of patients. Delirium is associated with increased morbidity in terminally ill patients and can interfere with pain and symptom control. ⋯ Haloperidol and other newer neuroleptics are safe and effective in eliminating delirium for some patients. In approximately one third of patients, delirium can be managed successfully only by providing sedation.
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Scrutiny of the quality of medical care near the end of life is increasing. Experts have begun to define and conceptualize quality of care for dying patients and are developing measurement tools to assess quality of care in this population. ⋯ Approaches for measuring the processes and outcomes of end-of-life care are discussed. Approaches for initiating quality assessment of end-of-life care among geriatric patients are suggested.