Health Articles

In one sense, a discussion of quality of life issues and their influence on establishing therapeutic objectives for the elderly is inappropriate in this book. The chapter title itself reeks of ageism, implying that ill elderly people have distinct quality of life concerns that require a change in traditional therapeutic objectives. But the goals of medical treatment have not changed since the time of Hippocrates, and a patient’s age should not affect a consideration of them. Medicine and its practitioners cure when possible, while always caring and relieving suffering.
Although age per se should not become part of the equation for setting treatment goals, several phenomena that are more prevalent with increasing age affect these goals and thus intrude upon this discussion. Chronic disease, physical disability, pain and suffering, cognitive impairment, institutional confinement, diminished life expectancy, heavy health care utilization, accumulated losses, and social isolation, although not unique to old age, are closely associated with it and demand attention when considering ways to enhance quality of life for persons receiving medical care.
Quality of life assessment is a thorny concept, in some ways more suited to philosophy than to medicine. In the context of health care, the focus on quality of life should be narrow, referring to a particular patient’s experience. The phrase “quality of life” does not imply any absolute standards; in the absence of disease or medical treatment, quality of life is an intensely personal and thus variable concept. Most people are comfortable talking about their own quality of life, but when asked to determine it for another person, they become appropriately uncertain and reluctant. Frequent and frank discussions with the patient about goals and aspirations for late life allow the physician to act in the most informed and useful way on the patient’s behalf.
Concrete, objective parameters may help guide clinicians in treating elderly patients when certain phenomena suggest the need to modify therapeutic objectives. Examples of useful indicators include the presence and severity of suffering (either mental or physical) or pain, the likelihood of having previous lifestyle and pleasures restored by treatment, the prognosis for survival, and the prospect that the disease or treatment will cause suffering. Regardless of the patient’s age, the adverse impact of a proposed diagnostic test or treatment should always be scrutinized and compared with the potential benefit. Coexisting conditions may influence the net gain or harm, but in principle the need to modify therapy remains unchanged by patient age. These and other ethical issues are discussed more fully in Ch. 109.
Chronic disease accompanied by chronic functional impairment is increasingly common with age (see Ch. 17). Some 50% of noninstitution-alized elderly persons have limitations in performing activities of daily living, and more than 80% have at least one chronic disease. More than 33% cannot perform major activities independently; 5% are home-bound. About 15% of those over age 75 are homebound; the figure rises to 25% in those over age 80. More than 80% of US health care resources are devoted to chronic illness, and 80% of deaths after age 65 are attributed to chronic disease. Successful treatment of chronic conditions requires a shift in traditional therapeutic emphasis from cure to continuing care. Management that emphasizes improving function, postponing deterioration and disability, and preventing secondary complications characterizes the best of geriatric health care. These principles are merely good common sense applied to therapeutic objectives in the care of older patients.
Cognitive impairment itself does not require a change in therapeutic objectives but does deserve consideration. The severity of loss and its functional impact should be measured and fully evaluated before deciding whether to modify treatment plans. Even a transient iatrogenic discomfort that cannot be explained to an elderly demented patient may require a change in clinical approach and treatment goals. Explanations to demented patients must be made with special care, and obtaining consent is fraught with difficulty.
Diminished life expectancy is another important factor in considering treatment objectives. A patient who has only months of life remaining should not have to spend them enervated, nauseated, and confined by oppressive chemotherapy. When the prognosis for a specific disease indicates a short life span, planning treatment in light of life expectancy is reasonable—regardless of the patient’s age. But when life expectancy is based on predictions related to the cohort (eg, 19 yr for a 65-yr-old woman, 14 yr for a man), variability among individuals is so great that calculations based on these data become meaningless. Who is to say that coronary artery bypass surgery with a high probability of improving function should be withheld from an 82-yr-old based on a prediction of “only” 5.3 yr of life remaining? And despite an average of 12 yr of life remaining for a 75-yr-old woman, how can one know if a particular patient will deviate a great deal in either direction from the mean? Finally, it could be argued that older people cherish their last few years, thus increasing the importance of preserving life through medical intervention, whether heroic or ordinary.
Nursing home residents have a disproportionately high prevalence of the characteristics that can affect treatment goals, including reduced life expectancy, poverty, cognitive loss, physical disability, chronic disease, pain and suffering, accumulated losses, and social isolation. Despite these negative characteristics, quality of life is very personal and subjective; therefore, a physician must accurately summarize the treatment issues and present them clearly in terms the patient can understand. Informing the patient and respecting autonomy is crucial, regardless of the patient’s age or dwelling. Only when the patient is an informed participant in the decision can the physician be comfortable in modifying treatment objectives. When the patient is unable to participate in such discussions because of cognitive loss, family or friends intimately familiar with the patient’s lifestyle and preferences may serve as a proxy for these decisions.
In some cases when life expectancy is diminished and suffering is severe, the patient or proxy may request euthanasia. However, active termination of life has traditionally been forbidden in medicine, and many believe rightly so. Confusing life protection and preservation with purposeful intervention to end life might make physicians and patients uncomfortable and suspicious. Yet in certain clinical situations of hopelessness and suffering, death is the end of pain, not the end of meaningful life. Accordingly, physicians have recently undertaken a re-examination of the bioethical basis for considering assisted suicide. In Holland, legislation has been enacted allowing physicians to end life in carefully specified circumstances of hopeless deterioration (see Ch. 109).
In old age, many phenomena occur that may argue for altering the usual therapeutic objectives. But these phenomena demand individual consideration, and age is largely irrelevant. The quality of human life is, for the most part, a concept that each person must consider; if quality of life becomes a criterion broadly applied to populations when making health care decisions, it will produce more complexities than solutions. Special attention must be given to the personal characteristics of older patients. Including patients in making decisions about treatment usually enhances their quality of life and brings greater satisfaction to the physician.