Abstract
Dear Editor:
Mr. B. was an 85-year-old patient with severe ischemic heart disease and high blood pressure. He was brought to the geriatric service of our general university hospital because of falls. Right arm paresis and delirium were present at admission. Computed tomography (CT) scan showed a large hypodense left fronto-temporal mass with peripheral edema suggesting glioblastoma. Age and poor general condition precluded any specific treatment. Neither advance directives nor proxies were present. The expertise of the pain and palliative care consultation team (PPCCT) was requested because of corticosteroid-resistant headache. Morphine (15 mg/d subcutaneous) was introduced with rescue doses and increase by 30% if necessary. Because of continuous deterioration of clinical condition and onset of agitation, the dose of opioids was rapidly increased without respecting the 30% ladder with no clinical improvement. The PPCCT suggested to look for a reversible etiology of delirium and to rotate opioids but the team directly in charge of the patient increased the dose of opioids to 75 mg/d. The explanation was: “Mr. B. will die in any case.” Five days later Mr. B. died, said to be comfortable during the last hours of life.
A few days later, the PPCCT team took the opportunity to discuss the whole management with the team in charge of the patient. The suffering of the patient was recognized by all health professionals and the rapid increase of the opioid doses was considered an adequate response. No further problem was mentioned.
Comments
Promotion of good communication between the patient, the team, and the proxies is crucial in palliative care. This communication should allow discussion between patients, proxies, and health professionals and optimal symptom assessment. However, in geriatric medicine, cognitive impairment is a challenge for PPCCT because 40% of the patients are demented or present with delirium at the first consultation (data not shown). Over the years, our PPCCT has been confronted with many problematic end-of-life situations of elderly patients who were given rapidly increasing doses of opioids with the goal of relieving suffering, which was most often related to pain or delirium. Such end-of-life situations should thus have been anticipated so as to discuss goals of care and elicit patients' and proxies' preferences. 1 The physicians directly in charge should discuss with the care team, the patient, and the proxies before withholding life-maintaining measures to adopt a symptomatic approach and eventually recognize that death is close. 2 In practice, this is not always possible because of sudden worsening general condition or cognitive impairment.
Suffering is a subjective phenomenon for which only patients can determine the level of tolerability. Suffering encompasses but is not limited to pain. In case of communication impairment and in the absence of proxies, the team in charge can best estimate the degree of discomfort and the level of tolerable suffering.3,4 Physicians have the duty to distinguish the type of suffering and to treat the underlying causes, if any, for which they may use pharmaceutical interventions at the end-of-life. 5 A detailed treatment plan could thus be anticipated to include symptomatic treatment, hydration, nutrition, and palliative sedation if needed.
Ageism is defined as “any attitude, action or institutional structure which subordinates a person because of age.” 6 Even if death occurs far more commonly in older rather than in younger patients, the evidence-based end-of-life care in older adults is sparse. 7 Even if there is evidence that the potential life-shortening effects of opioids is very limited and that the symptomatic benefits of treatment predominate in such cases, it is very important that ageism does not make the asumption of individual's preferences because of age, i.e., “in any case he will die, he is old or very old.”8,9
Although geriatric medicine and palliative medicine share much in common, including emphasis on optimizing quality of life, much work and professional education has to be done to better identify nurses' and physicians' attitudes advocating the increase of the dose of opioids rather than to distinguish the type of suffering. 10 To treat the causes with adequate pharmaceutical interventions would then help to relieve suffering at the end-of-life.