On a daily basis both in hospitals and in our offices we deploy a dizzying array of medications and technologies designed to extend life. The problem is that most of these interventions have rarely been tested on frail seniors and have a much greater chance of causing them harm than providing benefit. Yet “rescue” care for frail seniors continues to be routine – a practice that violates the ethical standard of informed consent.
Frailty is a “multidimensional syndrome of loss of reserves (energy, physical, ability, cognition, health) that gives rise to vulnerability”. Younger seniors generally speaking, are not frail. In fact, Canadian seniors 65 to 75 years old report limitation in activities of daily living similar to those adults aged 45 to 64 years.
However one quarter of seniors 85+ report moderate to severe functional limitation and the overall weighted prevalence of frailty in older seniors is about 30%. Dementia is an important element of frailty with the stages of mild, moderate and severe dementia mirroring those of frailty.
Far more than age, frailty predicts poor prognosis, limited lifespan, a higher rate of surgical complications and longer hospital stays. While the extraordinary advances of modern medicine work well for middle-aged adults and seniors who are not frail, for frail seniors these interventions are far more likely to cause harm than provide benefit. Many elective procedures such as angioplasty, knee replacements and colonoscopy have a much higher rate of post-intervention delirium with prolonged hospitalization followed by admission to residential long term care, when practiced on frail seniors. Frailty, much more than age, predicts this outcome.
And yet we rarely recognize frailty and dementia as an independent risk factor. It takes time to carefully gather the necessary information to understand if frailty is present. Even when we do recognize the presence of frailty, we often fail to educate seniors or their families about what to expect.
When a frail older person comes into the emergency department or presents to our offices, we simply do what we are trained to do which is try to fix each broken-down part. We apply our medical decision rules and algorithms for each disease to that person. In many ways, it is much easier to do this than the careful digging required to diagnose and stage frailty, to say nothing of having the difficult conversations with patients and their families about the prognosis associated with frailty. In his most recent book American surgeon Atul Gawande observes that doctors don’t know when to stop intervening and patients don’t know how to tell them to stop.
However, without determining how much frailty is present and the associated prognosis, we are withholding crucial information for seniors and families to make informed decisions. Simply proceeding down a given “rescue” pathway without providing this information is a gross failure to provide informed consent and arguably unethical.
Drs Paige and Moorhouse, two geriatricians from Halifax who have studied decision-making in this demographic, write that all frail seniors have a right to good information about the following questions: “Which health conditions are easily treatable, and which are not? Is there frailty and how will frailty make treatment risky? How can symptoms be safely and effectively managed? Will the proposed treatment improved or worsen function or memory? Will the proposed treatment require time in hospital and if so, for how long? Will the treatment allow more good quality years, especially at home? and What can we do to promote comfort and dignity in the time left?”
Given a better understanding of the prognosis of frailty there is strong evidence that many would opt for not proceeding with life extending intervention. It should be the right of seniors and their families to be adequately informed about their degree of frailty and what to expect. Without providing them this information, “rescue” care for these frail seniors is unethical.
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Really appreciated your article. For me, it speaks into the need for ‘the gift of advanced care planned’. We, as healthcare professionals, need to promote these discussions whenever possible especially in the presence of the most responsible practitioner.
I wonder how much of the cultural shift required is dependent on our funding models & the need for the MOH’s to shift resources (not adding) to encourage & compensate more Healthcare Professionals to have ‘the conversation’.
Thanks again for the reflective thoughts! Jeanne Murko-Wust, BScN, MAL,GNA
Any discussion about the “ethics” of rescue care for the frail, who are most often elderly, needs to be accompanied by at least an equal concern on the part of clinicians and policy makers about ending the epidemic of hospital errors that is the third-leading cause of avoidable death in Canada for patients in every condition.
During my elderly mother’s six-month hospitalization following a traumatic brain injury in 2010, it was not the “rescue” interventions that caused her harm, but the tidal wave of hospital errors that was inflicted on her at two separate facilities. Had we listened to the professionals who repeatedly warned that her demise was imminent, and had we not regularly intervened to prevent further mistakes that threatened her life, she would not be alive today.
Last week, she celebrated her 93rd birthday in the home where she was born. She is looking forward to her fifth Christmas since her hospitalization. Though her life has major limitations, she still appreciates her Irish Setter, books and gardens as much as before, and she laughs, reads newspapers and enjoys full meals with her family every day. She, and we, would have been deprived of this joy had we allowed her to be treated by the healthcare system as just another statistic.
I am glad to hear an opinion on this that more closely resembles my own. Most of my 88-year-old mother’s health troubles stem not from her age but from medical errors, misdiagnoses, missed diagnoses and lack of appropriate treatment over the last 20 years. Now that she is in the over 80 club, her doctors seem to think that any treatments are pointless and so she is undertreated and over-medicated. 75, 85, 95 or 100 only sounds impossibly old until you or someone you love reaches that age, and at that point you realize the value of human life and you hold onto it.
Thanks Margaret, of course you echo the work of Dr. John Sloan who says much of the same in his book “The Bitter Pill” and interestingly reflect the problem recently discussed in the Vancouver Sun regarding moral distress among hospital workers (mainly ICU) who are often faced with having to undertake heroic treatment when it is both unnecessary and harmful. Sloan makes the distinction between preventive treatment, curative treatment and symptom management to maintain function in the frail elderly. That population is generally beyond prevention as they already have the diseases we usually try to prevent (chronic heart disease, COPD, arthritis, dementia,etc.), will not be cured, but do need pain and other symptom management to maintain the highest level of functions that they can. Wet end of over do the preventive and curative types of treatment and under utilized the symptom management. Sloan also notes as you do that lack of evidence for much of the treatment the frail elderly get is not derived from clinical trials as that population is not usually included in clinical trials.
Should read “Drs. Paige Moorhouse & Laurie Mallery, two geriatricians from Halifax …”
Thanks Margaret. This piece resonated with me, as a clinician but also as the son of an 89 year old mom who in the last two years has gone from vigor to frailty (still independent but definitely frail). Is there a particular scale of frailty that you suggest we should use?
The gold standard for the assessment of frailty is a comprehensive geriatric assessment (CGS). Scale options include the Frailty Index and the Phenotypic model. Both are valid and predict important outcomes (death, institutionalization, hospitalization, falls). The problem is that scales only identify frailty, but do nothing to identify the domains that are driving frailty (and hence the areas clinicians and families may wish to focus on when preventing further functional decline and optimizing quality of life).
Try “The identification of frail older adults in primary care: comparing the accuracy of five simple instruments”, Hoogendijk, et al. Age and Ageing 2013