Helping older patients and their families decide about end-of-life care

Three-fourths of those who die in America are 65 or older. In all but the cases where death is sudden and unexpected, decisions frequently must be made about whether to limit treatment. In this paper, we provide a framework and specific tools that may help physicians in talking to older patients and their family members about end-of-life care. After briefly reviewing the demography of dying and methods of advance care planning, we propose a four-step process for deciding about end-of-life care: 1. Identifying patient preferences. 2. Communicating about medical prognosis. 3. Defining goals of care. 4. Implementing a management plan consistent with those goals. The paper concludes with special considerations about four common experiences of dying as an older person: chronic diseases with acute exacerbations (e.g. congestive heart failure or chronic obstructive lung disease), cancer, end stage dementia, and unexpected catastrophic decline.