Abstract
Substantial shortfalls in the quality of palliative care of the elderly can be attributed to 5 fundamental flaws in the way end-of-life care is currently delivered. First, palliative care is viewed as a terminal event rather than a longitudinal process, resulting in a reactive approach and unnecessary preterminal distress in elderly patients suffering from chronic, slowly progressive illnesses. Second, palliative care is defined in terms of a false dichotomy between symptomatic and disease-focused treatment, which distracts attention from the proper focus of healing illness. Third, the decision about whether the focus of care should be palliative is not negotiated among patients, family members, and providers. Fourth, patient autonomy in making treatment choices is accorded undue prominence relative to more salient patient choices, such as coming to terms with their place in the trajectory of chronic illness. Fifth, palliative care is a parallel system rather than an integrated primary care process. A new theoretical framework—the TLC model—addresses these flaws in the provision of palliative care for elderly persons. In this model, optimal palliative care is envisioned as timely and team oriented, longitudinal, collaborative and comprehensive. The model is informed by the chronic illness care, shared decision making, and comprehensive geriatric assessment research literature, as well as previous palliative care research. Preliminary results of an intervention for elderly assisted living residents based on the TLC model support its promise as a framework for optimizing palliative care of elders.
Footnotes
Conflict of interest: none reported
Funding support: Funded in part by a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar Program (RWJF GPFSP) career development grant, No. 039176 (Dr. Jerant) and a RWJF Promoting Excellence in End of Life Care Program grant, No. 035490 (Dr. Meyers).
Versions of this paper were presented in part at the RWJF GPFSP Annual Meeting, Ponte Vedra, Calif, December 4–6, 2002?
- Received for publication September 16, 2002.
- Revision received January 17, 2003.
- Accepted for publication February 10, 2003.
- © 2004 Annals of Family Medicine, Inc.