RE: Frail older adults should receive early integrated Palliative Care
References
Sarah Engelhart, Nathan M. Stall, Kieran L. Quinn. Considerations for assessing frail older adults requesting medical assistance in dying. CMAJ 2022;194:E51-E53.
Stow D, Spiers G, Matthews FE, et al. What is the evidence that people with frailty have needs for palliative care at the end of life? A systematic review and narrative synthesis. Palliat Med 2019;33:399–414.b n
Zimmermann C, Wong JL, Swami N, et al Public knowledge and attitudes concerning palliative care BMJ Supportive & Palliative Care Published Online First: 07 October 2021. doi: 10.1136/bmjspcare-2021-003340
Hui D, Hannon B, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: team-based, timely, and targeted palliative care. CA Cancer J Clin 2018;68(5):356–76. https://doi.org/10.3322/caac.21490.
Oliver D. Improving patient outcomes through palliative care integration in other specialised health services: what we have learned so far and how can we improve? Ann Palliat Med 2018;7(Suppl 3):S219–30. https://doi.org/10.21037/apm.2018. 05.05.
The Canadian Society of Palliative Care Physicians appreciates the detailed commentary “Considerations for assessing frail older adults requesting medical assistance in dying”. It perplexed us that the authors did not recommend palliative care addressing the needs and suffering of those with frailty. The authors referenced a study that identified varied physical (pain in particular), psychological and support needs that would benefit from palliative care, but also noted that patients with frailty are less likely to receive palliative care or die in hospice.
As noted, in frailty predicting that death is reasonably foreseeable is challenging, especially in those with mild frailty. Not mentioning palliative care for those whose death is “not reasonably foreseeable” raises the persistent myth that palliative care is only for those who are dying in the near future. A good number of studies now have demonstrated that positive patient outcomes result from palliative therapies, particularly when applied early in the illness trajectory. Evidence also supports better outcomes with palliative care in non-cancer illnesses, though research depth lags behind cancer.
It is imperative that all practitioners are aware and willing to incorporate palliative approaches throughout the trajectory of frailty as a means of prevention of suffering. As we know, frailty overlaps with multi-morbidity and in these situations, it often requires a team approach to care that focuses on symptoms and sources of suffering, rather than disease indices.
We recommend all frail older adults receive early integration of palliative approach to care to improve their quality of life, based on their needs and preferences.