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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
One Small Step Toward a Comprehensive Approach to Palliative Care in the Elderly
Will Better Assessment Enhance End-of-Life Care?
Improving palliative care for the elderly: Moving a model forward
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Anthony F. Jerant, Sacramento, California, USA Assistant Professor, Department of Family and Community Medicine, UC Davis School of Medicine
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Mehr makes some excellent points in his letter regarding the limitations of our initial evaluation of the TLC model. Our primary goal in conducting the project was to characterize the most pressing unmet palliative care needs of the assisted living population, to better inform our then-developing TLC model. A second goal was to pilot test a limited scope intervention grounded in aspects of the TLC model. We are currently completing final analyses to determine the impact of the intervention on subject outcomes, and will submit them for publication in the near future. However, preliminary results suggest that, consistent with Mehr's comments, some changes in our intervention approach will likely be required to optimize its impact, and we have already begun planning future research with such modifications in mind. For example, as Mehr correctly points out, non-physician team members could deliver many aspects of our intervention. Because our initial project was primarily funded by a small career development grant, we did not have the resources to assemble a multidisciplinary team. However, we are currently developing a more ambitious proposal for a better-funded, "next iteration" intervention that will include the Team-oriented aspect of the model. As Mehr also notes, the intensity of intervention influences uptake of recommendations. Our preliminary results do in fact suggest that the intensity of our intervention may need to be increased in order to achieve adequate levels of uptake, but probably only for certain types of recommendations. For example, for recommendations regarding completion of advance directives, letters to the patient, involved family members, and primary provider were fairly effective in achieving uptake. By contrast, for recommendations regarding falls and fall-related injury prevention, we found letters alone seldom resulted in uptake. To account for these findings, we are planning our future iteration of the intervention to include a range of intervention intensities, appropriately matched to the palliative recommendation at hand. In regard to advance directive recommendations, for example, the need for additional reinforcement is fairly minimal and will likely entail simple measures such as follow-up phone calls. By contrast, for fall-related recommendations, we will need a more comprehensive approach. This will include an approach to communicating recommendations to subjects and their family members that is more firmly grounded in health behavior change theory and explicitly accounts for important mediators of health behavior such as self-efficacy. It will also include an expanded role for facility staff and non-physician professionals (e.g. physical therapists) and on- site balance and gait training classes as a way of overcoming logistical barriers like having to rely on insurance approval of non-“acute need” physical therapy referrals. We must take issue with Mehr's claim that our pilot intervention did not address the Collaborative element of the TLC model. While it was perhaps unclear in our preliminary report, the vast majority of our study encounters were co-attended by informal caregivers (mostly adult children) for our subjects. Furthermore, discussions regarding unmet palliative care needs and prioritization of intervention involved not only the subject and intervention physician but also their informal caregiver(s) and, when indicated, facility staff and the subjects' primary provider. We plan to continue to employ this collaborative approach and expand on it where feasible in our follow-up projects. Finally, in response to Mehr's concern about how our model can best be implemented, it is worth reiterating that we proposed the TLC model as a general framework within which a variety of specific interventions might be developed. While we plan to continue to pursue our assisted living facility-based line of inquiry, other elderly patient sub-populations (e.g. community-dwelling) and intervention settings (e.g. outpatient clinics) might also be targeted. Furthermore, a variety of approaches to intervention (e.g. conferences with all the stakeholders including the primary care provider) might also be explored. Each of these variations will of course come with strengths and limitations. We are gratified to see this interest in and discussion of our work, and we look forward to an ongoing dialogue. Competing interests: None declared |
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David R. Mehr, Columbia, Missouri, USA Associate Professor of Family and Community Medicine, University of Missouri-Columbia
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Jerant and colleague's interesting paper proposes a new model of palliative care for elderly persons. The model aims to address important issues in the care of the chronically ill elderly, and the model components appear pertinent. The authors also make an important distinction between shared decision-making and autonomous treatment decisions. However, the information supplied on preliminary application of the model focuses simply on a longitudinal assessment process. As the authors note, comprehensive geriatric assessment (CGA) is typically targeted at individuals who are not thought close to the end of life. The authors have supplemented typical instruments used in CGA with additional instruments to address domains of palliative care, and they report findings to the resident, primary clinician, and family members. Nonetheless, the proces described does not directly address the Team- oriented or Collaborative components of the model. Clearly much of the assessment could be done by a multidisciplinary team (as is standard in CGA) rather than an individual physician. However, one of the major issues throughtout the history of CGA (outside the hospital setting) has been the translation of recommendations into practice. Although written communication is pertinent, it is not clear that this is a strong enough intervention to alter care or enhance shared decision making. It is also not clear how this intervention will involve nurses, social workers, or other relevant team members. While I applaud the effort to move beyond our dysfunctional system of end-of-life care, I am not clear how the proposed TLC model would operate or to what extent it is being tested with the reported preliminary application. Competing interests: None declared |
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Joshua M. Hauser, Chicago, IL Palliative Care Physician, Buehler Center on Aging and Northwestern University
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Jerant and colleagues' article, "The TLC Model of Palliative Care in the Elderly" offers two crucial insights into the issue of palliative care and the elderly. The first is their clear outline of a framework for palliative care needs and current shortcomings among the elderly. The second is their design and preliminary findings of an intervention to improve care. In terms of the shortcomings in our current thinking about palliative care, the authors identify several areas: the idea that palliative care is about terminal care, the lack of integration with traditional care, and the unrealistic premium on "patient autonomy" at the expense of thinking about illness context. What each of these illustrate is how challenging it is to envision excellent palliative care because it is unlike two stereotyped trajectories that we sometimes have in medicine: One, that patients become ill and are then cured. Or two, that patients become so ill that there is nothing more we can do. Excellent palliative care tries to find a balance between these. In terms if the intervention part of their paper, Jerant and coleagues describes an intervention for palliative care in assisted living that tries to make their TLC (Timely, Longitudinal, Collaborative and comprehensive) approach concrete. In this intervention, residents had a series of comprehensive palliative care assessments and recommendations that were then sent to the resident, family member and primary provider. The preliminary results show significant deficencies in palliative measures being provided for residents. Although this is a discouraging finding, the authors are not satisfied to leave it there: their study is an ongoing one and the question of whether this intervention improves these shortcomings is the next and important step that they have plannned. Background references Reynolds K. Henderson M. Schulman A. Hanson LC. Needs of the dying in nursing homes, Journal of Palliative Medicine. 5(6):895-901, 2002 Dec. Parker-Oliver, D; Porock, D; Zweig, S; Rantz, M; Petroski, GF. Hospice and Nonhospice Nursing Home Residents, Journal of Palliative Medicine, 6 (1): 69 -- 75, 2003. Competing interests: None declared |
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