CANCER IN ELDERLY PEOPLE: WORKSHOP PROCEEDINGS by Institute of Medicine of the National Academies

Author:Institute of Medicine of the National Academies
Language: eng
Format: epub
Tags: Health and Medicine : Aging. Health and Medicine : Diseases - Cancer
Publisher: NATIONAL ACADEMY PRESS
Published: 2007-04-02T00:00:00+00:00

Figure 2-12 is an example of one algorithm for managing older patients with cancer. Unfortunately, the initial construct separates patients into frail or nonfrail. The frail will get palliation, but there is no definition of this palliation in any detail, and the nonfrail will go through a series of decisions and may or may not get treatment without defining very clearly what we mean by life-prolonging treatment versus palliation.

The models for geriatric cancer care need to be made more sophisticated. I support using a comprehensive geriatric assessment. The assessments that are currently being used include functional status, comorbidity, socioeconomic issues, nutritional status, polypharmacy, and geriatric syndromes. However, they need also to consider a good symptom assessment scale, information about the patient’s shared decision-making process, where patients stand on advance directives, and goals of care. This is an opportunity where palliative care and geriatrics can come together, al though, the National Institute on Aging repeatedly tells me that they focus on aging, and dying is not something they want to talk about.

How do we interface geriatrics and palliation? I think the domains clearly involve access to care, patient-centered care, and some ethical issues that are at the forefront and need a great deal of discussion and leadership: issues of nutrition and hydration, of sedation, where physician-assisted suicide and euthanasia really come to the fore. They are part of the public fabric of our discussions about these issues—involving the role of volunteers, funding, research, and challenges to organizational structures. Clearly, some open, transparent discussions about these are critically important.

Figure 2-13 displays the formalized, integrated model that addresses both curative and palliative care for chronic progressive illness. In the care of the cancer patient we should build into the algorithm in Figure 2-12 that patients, depending on their needs, will receive palliative care. This is different than supportive care, which, in the cancer literature, is about treating symptoms caused by chemotherapy; it is about blood products. There should be explicit data about the use of supportive therapies, but they are not palliative care services. There are clear national guidelines for palliative care and guidelines for who should receive that care. These need to be interfaced more closely with geriatrics.

FIGURE 2-13 Integrated model for chronic progressive illness.

SOURCE: WHO Expert Committee, 1990.

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