Chambaere, Kenneth

Swiss Medical Weekly

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Ghent University Academic Bibliography

Viewpoint | Published 22 March 2020 | doi:10.4414/smw.2020.20206Cite this as: Swiss Med Wkly. 2020;150:w20206The oldest old: the newest focus in end-of-lifecare?Chambaere KennethEnd-of-Life Care Research Group, Ghent University and Vrije Universiteit Brussel (VUB), BelgiumCurrently, Swiss Medical Weekly boasts a highly interest-ing and time-relevant contribution of Hug and colleagues,titled “Medical end-of-life decisions in the oldest old inSwitzerland” which examines the differences between theoldest old and younger patients in terms of the frequencyof various end-of-life decisions such as intensified allevia-tion of pain and other symptoms and, most notably, with-holding and withdrawing life-sustaining treatments [1].This study is time-relevant as it is an inescapable truth thatwe are being confronted with a rapidly ageing populationin many countries around the world. Already more thanhalf of all Swiss deaths concern people over the age of 80,with a further increase expected in the future. These grow-ing numbers of people also have increasingly long trajec-tories of health decline – both physical and cognitive – andof chronic and degenerative illness progression, dependingon their specific afflictions. Needless to say, this is puttinga high strain and pressure on the medical healthcare systemas well as on society and our communities to provide ad-equate care for our oldest old. Not only is throwing moreprofessionals at the problem not a feasible solution, but al-so the number of family caregivers available to every olderperson with healthcare needs is set to dwindle in the nearfuture [2].Older people living with serious illness and multiple old-age related co-morbidities are thus regarded as a group ina highly vulnerable position when it comes to their med-ical care and decision making at the end of life. They arelargely unempowered and prone to medical paternalismand ageism [3]. Likewise, their low functional status canlead to clinician powerlessness and therapeutic pessimismor nihilism [4]. As the authors assert: “The oldest old havebeen reported to have less access to specialist or palliativecare, to receive adequate pain and symptom treatment lessoften, and to be excluded from decision making more of-ten” [1].Though the authors did not specifically address end-of-lifecare for the oldest old in Switzerland, they did find thatold age seems to be a determining factor for the preva-lence of some types of end-of-life decisions, regardless ofcause of death, place of death, sex or marital status (allof which differ substantially across age groups). The re-searchers found a clear and consistent indication that life-sustaining treatment attempts (artificial nutrition and hy-dration, antibiotics, ventilator therapy, chemotherapy anddialysis) are decided against more often among the oldestold compared with younger age groups. Also, “the propor-tions of patients for whom a specific treatment was takeninto consideration […] decreased with age for [most stud-ied] types of treatment” [1].Though this is not necessarily unequivocal evidence of oldage being a decisive factor in end-of-life decision mak-ing, these findings are not very surprising as they matchwith (albeit scarce) international findings and debate [3, 5].Their real merit lies in our ability to reflect about poten-tial explanations and the issues involved. It will often bethe case that in older people the cost-benefit analysis of at-tempting life-sustaining treatment tips over to the negative(perhaps even to the point that the treatment is not evenconsidered): the gained quantity of life does not lead to anyimprovement in quality of life and/or does not weigh up tothe imposed burden for the patient. Often there will evenbe no chance of any meaningful improvement in their situ-ation. In those instances, there will indeed be an increasedaptitude and preparedness to discuss end of life (not neces-sarily a “tacit” consensus that death is nearing, as the au-thors suggest) [1].Above all, the older person him/herself needs to have a sayin the matter, if not at the moment of decision making, thenat least beforehand via, for example, advance care plan-ning conversations. This is the best way to avoid ageist rea-soning in end-of-life decisions for the oldest old, that is,attitudes that, all other things being equal, life (prolonga-tion) in very old age is no longer as meaningful as it is inyounger patients [3, 6]. Furthermore, considerations relat-ing to the difficulties of organising adequate care, to thestrain on the family or financial issues should be acknowl-edged but cannot readily be admitted as reasons to for-go life-sustaining treatment. As such, the age-old (no punintended) balancing act for physicians between therapeu-tic tenacity on the one hand, and therapeutic nihilism andageism on the other hand is intensified in end-of-life deci-sion making for the oldest old. This is what makes the old-est old a fitting group for more focused research in the fieldof end-of-life decision making.One other thought relating to the age disparities found inwithholding treatment at the end of life: one could positthat it is not so that physicians are not aggressive enoughCorrespondence:Prof. Kenneth Chambaere,PhD, Professor PublicHealth, Sociology & Ethicsof the End of Life, End-of-Life Care Research Group,Ghent University and VrijeUniversiteit Brussel (VUB),Campus UZGent, building6K3, room 012, C. Hey-manslaan 10, B-9000Ghent, kenneth.cham-baere[at]vub.beSwiss Medical Weekly · PDF of the online version · www.smw.chPublished under the copyright license “Attribution – Non-Commercial – No Derivatives 4.0”.No commercial reuse without permission. See http://emh.ch/en/services/permissions.html.Page 1 of 2when it comes to the oldest old, but can to the contrary beoverly aggressive when it comes to younger people whoare dying. Within current debate on the medicalisation ofdying and on therapeutic tenacity [7], it is certainly a ques-tion worth pondering.The authors have used a highly robust and trustworthymethod, even though, as with any research, there are ob-vious limitations. Although it is in itself of limited clinicalbenefit, it is important to repeat this kind of population-level research longitudinally to allow for analysis of evo-lutions in end-of-life decision making as a monitoring andreflection tool for practice and policy. However, the abovediscussion shows us that large-scale surveys tell us only thebroad story, providing a helicopter view of differences, butwithout the needed depth to definitively qualify or explainthem. As such, this research forms the basis and startingpoint for further focused insights. For instance, examiningdifferences in end-of-life age disparities according to caresetting or region will allow us to (begin to) uncover the cul-tural factors that are relevant in end-of-life decision mak-ing in the oldest old, both in terms of medical culture andin terms of public, patient and family attitudes, perceptionsand beliefs.Also, as the authors concede [1], population-level researchdoes not convey many insights on the appropriateness orthe adequacy of end-of-life decision making, and the con-siderations underlying end-of-life decisions. A next step isto study the influencing factors and conditions in whichdecisions are made in the oldest old, and to gauge dispar-ities in the quality of that decision making, from the be-ginning: who is involved?; to what extent and how are thepatient and family involved?; on what grounds are deci-sions made?; to what extent do different clinical and ethi-cal considerations come into play?The study convincingly shows the need for more attentionon this age group when it comes to end-of-life issues. Thesheer number and proportion of deaths in old age (84%)where explicit end-of-life decisions are made – and oftenmore than one single end-of-life decision [1] – is indica-tive of the pervasiveness of the issue in medical practice.Managing such situations well requires adequate training,support and coping strategies. It is rarely a simple andstraightforward process, involving many practical, clinicaland ethical considerations and different actors, which is notmade easier if it concerns a very old person. As such, thelikely considerable burden for all those involved, as wellas the manner in which these decisions are made, deservesall the attention it can get.Disclosure statementNo financial support and no other potential conflict of interest relevantto this article was reported.References1 Hug K, Penders YWH, Bischoff-Ferrari HA, Bopp M, Bosshard G.Medical end-of-life decisions in the oldest old in Switzerland. SwissMed Wkly. 2020;150:. doi: http://dx.doi.org/10.4414/smw.2020.20177.PubMed.2 Cohen J, Deliens L, eds. A public health perspective on end of life care.Oxford, UK: Oxford University Press; 2015.3 van der Heide A, Chambaere K. End-of-life decisions for older patientswho are approaching death. In: Van den Block L, Albers G, Pereira SM,Onwuteaka-Philipsen BD, Pasman HRW, Deliens L (eds.) Palliative carefor older people: A public health perspective. Oxford, UK: Oxford Uni-versity Press; 2015.4 Back AL, Rushton CH, Kaszniak AW, Halifax JS. “Why are we doingthis?”: clinician helplessness in the face of suffering. J Palliat Med.2015;18(1):26–30. doi: http://dx.doi.org/10.1089/jpm.2014.0115.PubMed.5 Bosshard G, Nilstun T, Bilsen J, Norup M, Miccinesi G, van Delden JJ,et al.; European End-of-Life Consortium. Forgoing treatment at the endof life in 6 European countries. Arch Intern Med. 2005;165(4):401–7.doi: http://dx.doi.org/10.1001/archinte.165.4.401. PubMed.6 Chambaere K, Bernheim J. End-of-Life Decisions. In: MacLeod R, Vanden Block L (eds.). Textbook of Palliative Care (subsection: Ethics ofpalliative care and end-of-life decision making). Cham, Switzerland:Springer; 2018.7 Clark D. Between hope and acceptance: the medicalisation of dying.BMJ. 2002;324(7342):905–7. doi: http://dx.doi.org/10.1136/bmj.324.7342.905. PubMed.Viewpoint Swiss Med Wkly. 2020;150:w20206Swiss Medical Weekly · PDF of the online version · www.smw.chPublished under the copyright license “Attribution – Non-Commercial – No Derivatives 4.0”.No commercial reuse without permission. See http://emh.ch/en/services/permissions.html.Page 2 of 2

The oldest old : the newest focus in end-of-life care?

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