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Box 12.3. Fighting polypharmacyA team in Israel has developed novel procedures for improving drug therapy for frail older people. For eachperson, every medication is re-evaluated to decide whether to continue with the same dose, reduce it ordiscontinue it completely. Decisions are evidence-based wherever possible and otherwise based on clinicaljudgement. Using this procedure resulted in the discontinuation of an average of 2.8 drugs per person with nosignificant adverse effects. Mortality and referral rates to acute care facilities declined, and the cost of drugsdropped substantially.The same practice and algorithm for drug discontinuation was found to be safe and effective among olderpeople living in the community (average follow-up 19 months); 47% of all drugs were stopped (3.7 ± 2.5 drugsper participant), and successful discontinuation was eventually achieved among 81%. Drug discontinuationwas not associated with significant adverse effects. Eighty per cent of the people discontinuing drugs and theirfamilies reported improvements in health, functioning, mental well-being and cognitive performance.Sources: Garfinkel et al. (7) and Garfinkel (8).References1. Walsh D et al. Palliative medicine. New York, SaundersElsevier, 2008.2. Hanks G et al., eds. Oxford textbook of palliative medicine.4th ed. Oxford, Oxford University Press, 2009.3. Bruera E et al., eds. Textbook of palliative medicine. London,Hodder Arnold, 2006.4. Solano JP, Gomes B, Higginson IJ. A comparison of symptomprevalence in far advanced cancer, AIDS, heart disease,chronic obstructive pulmonary disease and renal disease.Journal of Pain and Symptom Management, 2006,31:58–69.5. Seale C, Cartwright A. The year before death. London,Avebury Press, 1994.6. American Geriatrics Society Panel on Persistent Pain in OlderPersons. The management of persistent pain in olderpersons. Journal of the American Geriatrics Society, 2002,50(Suppl.):S205–S224 (http://www.americangeriatrics.org/products/positionpapers/JGS5071.pdf, accessed 1 December2010).7. Garfinkel D, Zur-Gil S, Ben-Israel J. The war againstpolypharmacy: a new cost-effective geriatric-palliativeapproach for improving drug therapy in disabled elderlypeople. Israel Medical Association Journal, 2007, 9:430–434.8. Garfinkel D. Symposium title: the war against polypharmacyrethinking and re-evaluation needed for each and every drugin the elderly (results of the good-palliative-geriatric-practicein the first 70 case reports). 19th World Congress of theInternational Association of Geriatrics & Gerontology (IAGGWorld) Congress of Gerontology & Geriatrics, Paris, 5–9 July2009. Abstract book. Journal of Nutrition, Health & Aging,2009, 13(Suppl. 1): SB7 116–4.9. Lynch T et al. Barriers to the development of palliativecare in the countries of central and eastern Europe and theCommonwealth of Independent States. Journal of Pain andSymptom Management, 2009, 37:305–315.10. Kovach CR et al. Assessment and treatment of discomfortfor people with late-stage dementia. Journal of Pain andSymptom Management, 1999, 18:412–419.40
13Advance care planningAdvance care planning involves discussion aboutpreferences for future care between an individualand a care provider in anticipation of futuredeterioration. These discussions may lead to severaloutcomes (1), although slightly different terms maybe used and the legal status of the statementsvaries.• An advance statement: a statement of wishesand preferences setting out the person’s generalvalues and views about care. It is not legallybinding.• An advance decision to refuse treatment: involvesrefusal of a specific medical treatment in apredefined potential future situation. It is legallybinding in some countries only if an individualloses capacity.• Lasting power of attorney: involves appointing aperson (an “attorney”) to take decisions on behalfof an individual if they lose capacity to do so.suggests that they might be useful in achievingimproved communication, higher satisfaction withdecision-making at the end of life and less anxietyand depression (5). In general, older people maychoose to undertake advance planning near to thetime of disability and illness (6).Older people may benefit from making advancestatements, including reducing the burden ofdecision-making on their families, but they alsohave concerns about associations with euthanasia;the possibility that preferences for care maychange; reluctance to think about death; and thetime needed for older people to trust professionalsenough to talk about such sensitive issues (2).There are also concerns that such statements arenearly always about treatment withdrawal ratherthan specifying active choices, with the fear thatthis feeds into prejudice against age and disability(3). Some doctors are unsure of the legal status ofadvance directives, which can result in them beingmisapplied or ignored (4). Advance care planninghas been used more extensively in North Americaand Canada than it has in Europe. However, a studyof the effect of advance directives in Switzerland© Catherine Higginson41
Page 1: PALLIATIVE CAREFOR OLDER PEOPLE:BET
Page 4 and 5: AbstractPopulations around the worl
Page 7 and 8: ForewordSocieties in the WHO Europe
Page 9 and 10: AcknowledgementsThe WHO Regional Of
Page 11 and 12: 1IntroductionPalliative care is an
Page 13 and 14: By 2050, estimates indicate that mo
Page 15 and 16: • training of health care profess
Page 17 and 18: individuals and their families. Hea
Page 20: Fig. 3.2. Factors associated with p
Page 23 and 24: (Table 4.1). After 15 years, more t
Page 25 and 26: • the last days of life and death
Page 27 and 28: Box 4.4. Gerontology Institute “1
Page 29 and 30: 5National awareness“You matter be
Page 31 and 32: 6Educational interventionsA well-pe
Page 33 and 34: Box 6.3. European Association for P
Page 35 and 36: initiated at an early stage in the
Page 37 and 38: 8Improving care for older people in
Page 39 and 40: 9Improving palliative care for olde
Page 41 and 42: Box 9.3. Training in end-of-life ca
Page 43 and 44: 10Improving palliative care for old
Page 45 and 46: References1. Higginson IJ, Sen-Gupt
Page 47 and 48: Financial help, such as the paid co
Page 49: (Box 12.2). Several drugs can often
Page 53 and 54: References1. Advance care planning:
Page 55 and 56: References1. Campbell H et al. Inte
Page 57 and 58: Box 15.1. Bus rounds as an educatio
Page 59 and 60: palliative care research initiative
Page 61 and 62: References1. Currow DC et al. A fra
Page 63 and 64: • Promote public awareness of pal
Page 65 and 66: 3. Invest in creative research into
Page 67 and 68: GermanyEberhard KlaschikCentre for
Page 69 and 70: United Kingdom (continued)Marilyn K
Page 71 and 72: The Maruzza Lefebvre D’Ovidio Fou

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