End-of-Life Care: Issues Relevant to the Geriatric Psychiatrist

Most deaths in the United States occur in the context of chronic diseases in later life and are too often accompanied by potentially remediable emotional or physical suffering. Geriatric psychiatrists and other mental health professionals can contribute meaningfully to the provision of optimal care during the final phases of life. This review provides an overview of end-of-life care, focusing on issues most relevant to the geriatric psychiatrist. The author examined palliative care textbooks and review papers to determine the topics to be included in this article, and searched computerized literature databases on these topics. Many of the recommendations provided herein stem from experts' clinical experience; however empirical evidence is also incorporated and critiqued. Topics covered include conversations with patients and families about end-of-life care; the evaluation and treatment of suffering, including pain, depression, suicidality, anxiety, and delirium; the role of individual and family therapies in caring for dying patients; capacity determination; advance care planning; withholding life-sustaining treatments; and “last resort” (and, in some cases, quite controversial) options, such as terminal sedation, assisted suicide, and euthanasia. The author also notes the relevance of such end-of-life-care considerations to patients with dementia. Geriatric psychiatrists' skills across these multiple domains are of particular usefulness. Through such clinical skills and the application of empirical research tools to the many unanswered questions in the care of dying patients, geriatric psychiatry can make increasingly valuable and visible contributions to improving quality of life for people suffering from life-threatening illnesses.

(Reprinted with permission from Am J Geriatr Psychiatry 2004; 12:457–472)