Thursday, February 4, 2010

The Cultural Distance Between Geriatrics and Palliative Medicine

I just read Chris Feudtner's brief piece, "The Breadth of Hopes," in the New England Journal.  Among other things, the article helps me articulate a difference between care at the end of life (last years, months, days) for many older people and care at the end of life for younger people. The distinguishing characteristic here is whether or not an individual has seen death coming, even distantly, and processed that, even a bit. Not all older people have done so, but many have – I think of the patient in David Reuben's recent JAMA paper who said, “When you’re 83, it’s not going to be 20 years.” And many families have come to a similar point when an older family member develops a life-threatening illness. In contrast, few younger people come to such a point before developing a serious illness. As one of my colleagues says, in geriatrics, our patients are nearer the end than the beginning, and they generally know that. This is not the case for younger people, and in our society, probably never the case for a parent with a previously healthy child.

I wonder if this difference might account for some of the cultural distance between geriatrics and palliative medicine, when such distance exists. Geriatricians may think, I do care at the end of life for many patients, and I do it well. Palliative medicine specialists may think, even geriatricians who provide great care at the end of life just don’t get an important part of palliative medicine, caring for people who won’t live a “natural lifespan,” who have had their hope for a long life dashed, and yet you may still hope for a miracle.

Does this resonate?

8 comments:

Anonymous said...

In my experience, there is significant variation among geriatricians re palliative care of their patients, and also that there is significant variation among palliative medicine physicians as well!! I liked Feudtner's discussion of breaking up the "architecture" of hope from a monolithic thing, to its component parts - different for different individuals & more workable than monolithic solid entities. I also appreciated his raising the issue of the emotional domain - of the potential for emotional manipulation. This is often the razor's edge of shared decision-making.

hospicephysician said...

In my hospice work I take care of young patients and geriatric patients with cancer. I do admit, that it is easier to take care of geriatric patients with cancer. As stated in your entry, many patients in their advanced age have "lived their lives." Many of them tell me, I had a good life and I'm ready to exit gracefully. The families seem to be more accepting. Statements like "Mom was a great mother and I don't want to see her go but she's tired now," or something similar are often said. Many times during my visit, the children who have grown and have children of their own are telling jokes and remembering good times about the patient as the family gathers around the bed of the actively dying patient. In contrast, younger patients are usually leaving parents and younger children behind. Their symptoms are harder to control because they are complicated with psychosocial and spiritual pain. Their parents feel an unnatural sequence in life that parents should die before their children. Young patients worry about the financial situation they're leaving their loved ones with. They worry about how this will scar their children. They often ask "why me," as they feel that it's too soon to exit this world. Yes, there is a difference and for the most part the difference can be significant.

Alex Smith said...

Thank you for bringing the article about hope to our attention, Seth. I think you've hit the nail on the head regarding a source of "distance" between geriatrics and palliative medicine.

We underwent extensive training in communication in my palliative medicine fellowship. The overwhelming majority was focused on exploring patients' fear of dying. Getting patients to talk about "it," helping them process, and journeying with them through what can be a terrifying experience on the one hand, and an opportunity for growth and connection on the other.

The majority of patients we cared for in my palliative medicine fellowship had cancer (90% at one hospital, 70% at the other), and were younger.

I contrast that with my current clinical experience caring for primarily older, frail patients with multi-morbidity, functional and cognitive impairment. These patients often have a greater sense of having lived through life's stages. This is a bit of a generalization, but the older patients frequently do not have that same sense of being "cheated" out of life's experience. In contrast, for many of the younger patients with cancer I cared for, this was the central issue. As hospicephysician so rightly noted, this existential suffering feeds into an experience of "whole body pain" that Cicely Saunders described.

The final caveat, is of course that this is complicated. New ideals of a "healthy" and "active" old age are resetting the expectations of many elders. I have had some experiences of older adults who hoped, and even felt entitled to decades more of a highly active, independent lifestyle, yet were facing the loss of thsoe dreams due to illness and dependancy. I've used my skills from my palliative care training to explore the "breadth" of hope for these patients, helping them identify new centers of meaning as they pass through states of progressive debility.

Eric Widera said...

This strongly resonates with me. There is great heterogeneity in how people react to an impending death. It does seem to be much more difficult on everyone involved when death occurs out of synch from one's perceived life stage. The most notable example I can think of, which hospicephysician points out, is when parents deal with the impending death of their child. It doesn't matter how old the child is, these parents inevitably "feel an unnatural sequence in life" that makes dealing with death so difficult.

ken covinsky said...

The similarities and differences between Geriatrics and Palliative Medicine are very interesting. I suspect we could learn a lot from each other by exploring them.

It strikes me that much of what we do to help the frail patients we see in Geriatrics is palliative in scope. We seldom call it that, perhaps because it is not viewed as end of life care. This perhaps gets at one of the differences between palliative needs in frailty compared to cancer: While consideration of prognosis may be important in frailty, the palliative needs are largely independent of prognosis.

Alex's description of his training is interesting, and I wonder how much this may influence cultural differences between the fields. I wonder if the differences in the types of patients fellows see in each field is justifiable in terms of the skills needed in each discipline.

Interestingly, while the prospect of death may often be less feared in the very old, to many elders, the prospect of coping with frailty and dependence creates great fear. This issue has recently been discussed on GeriPal. I am intrigued by Alex's suggestion that the communication skills taught to palliative care fellows may be very useful to Geriatricians in helping their patients live with frailty.

Drew Rosielle MD said...

I've been thinking about this as well lately. A few thoughts:
1) our training is different - I have had no particular training or knowledge outside of my medicine residency about falls, comprehensive geriatric assessment, dementia drugs, urinary incontinence, etc. My geriatrics colleagues who don't practice as palliative care specialists, while all swell people that I respect and rely on, don't have any particular training (beyond their residency etc.) in advaned cancer pain and symptom management, patient-family-clinician conflict and complex decision-making, prognostication outside of geriatric syndromes, etc.

None of this is to say that much of what geriatricians do is 'palliative' in the broad sense of the term, nor is it to take away from the reality that many geriatricians can (and actively do) practice as palliative specialists (and have been/are integral to our field - the academic base for palliative care has relied heavily, although by no means exclusively, on geriatricians). Hell, some of my best friends were trained as geriatricians....

Simply put, we have overlapping training and competencies, much like many other specialties (e.g. family and internal med, internal med and geriatrics, gyn and urology, cardiology and nephrology).

I think Seth's point is a valid one, and at least reflecting on my own, mostly hospital-based/consultative palliative practice, a substantial minority if not majority of my patients are under 60, and the issues can be quite different. That said, how often do we see patients who are older whose families are (at least initially) completely aghast at the thought that the patient is not going to live forever, and that Modern Medicine doesn't have the answers? The flip side of this is the fact that not a small percentage of my younger dying patients (e.g. 55 and under) face their deaths with equanimity, and acceptance, and gratitude for a life well lived although a few decades too short. This happens all the time, and perpetually humbles me. All this is to say I'm not 100% sure that age/life-cycle issues are fundamentally what is different.

As I think about this more, and I'm sure not everyone will agree with this, I think the big difference (apart from complex cancer symptom management) is the relentless focus in palliative care on goals of care - the foregrounding of these concerns (and all that attends it: assessing a patient's understanding of the natural history of their illness and prognosis, aligning goals of care with patient values, explicitly placed in a patient's understanding of her/his illness and expected course, etc) is what differentiates HPM specialists from geriatricians.

Feel free to dissuade me.

Green Tea said...

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Green Tea

Anonymous said...

very interesting ,thoughtful remarks and very relevant to daily practice
as some one who is actively practicing geriatric and palliative medicine in a clinic/home setting I feel the distinction(between the two)
is an artificial one and that the existence of such tension only adds to the fragmentation of care and consequent increased resource utilization while doing nothing to improve the quality of care
Consider a frail 82 yr old elderly patient with advanced chf with several comorbidities who sees a pcp,cardiologist,nephrologist and a geriatrician
I believe a geri pall specialist(assisted by an interdisciplinary team) with will be best suited to manage such a patient addressing and managing the following :
1 Prognostication of significant end stage disease( rarely done by other specialists /pcp mainly due to time constraints and lack of sophistication or is addressed late in the course of the illness after a slew of hospitalizations))
2. Managing chf ( or for that matter any end organ disease)with sub specialist input ( one finds ,on occasion, cardioprotective drugs such as ace ,spirinolactone ,beta blockers missing in their medication regime
mainly because they were 'too old' resulting in an ever increasing downward spiral of function at which point low PPS scores will allow patient to become 'hospice eligible')
3. Relevant geriatric syndromes that can be reversed when addressed-some that come to mind include partial adherence, polypharmacy, cg stress
4. Symptom control : absolutely essential for QOL
5 Transitional care allowing seamless, painless(for the family and the er/hosp providers) and timely transition to exclusive home based progams without the irrational and costly turbulence that precedes such transitions with ever increasing hospitalizations and exposure to multiple providers with varying skills( a recent patient that I followed for 1 wk in hospice before she died -had in the preceding 5 m -3 hospitalizations,3 snf stays,45 different physicians,500 lab tests,50 imaging studies and 25 procedures - and a shocked ,disoriented family to boot
I believe most frail elderly patients with chronic illnesses (and we can quibble about the age cut off ) should have at the primary care level a geri pall specialist who coordinates the care .
Most medical homes today have a primary care physician(fp/im )assisted by RN case managers who managing these patients .
My conclusion is (and I would welcome responses) that the complex ,frail elderly patient with several comorbidities will be best served by a team that is headed by a geri-pall specialist with the usual ancillary paramedical providers ie cm,sw etc – across the continuum at most or all point of service settings -
This will provide cost effective best quality care .Presently the care we provide such patients in both the fee for service and managed care sectors is fragmented,with compromised quality fraught with iatrogenic hazards and increased costs with poor outcomes