Death and Dying - Stages of Life | Human Development and Aging ...

Death and Dying
Dying during the 1990s is different from dying during the early 1900s, when most geriatric patients were born. At the turn of the century, most deaths occurred at home, and the death rate among children was particularly high.15 Most deaths currently affect people over age 75, and more than 70% of Americans die in institutions, either hospitals or nursing homes.16 Deaths in hospitals are often traumatic for surviving family members. The risk of an adverse health event may also be greater during times of bereavement, especially when the survivor is elderly.17

There is a strong presumption for prolonging life, almost at any cost, among many physicians. Older persons, and even some younger ones with terminal illness, may not share this value. Instead, the goals of relief of suffering, enhancement of function, and increasing the quality of life become predominant. How should "quality of life" be defined? One person's perception of quality may be at odds with that of another. Physicians are poor predictors of what older persons consider to be low quality of life.18 Older persons need open, honest appraisals from their physicians as to the interventions that may provide benefits and the limitations of medical care. Although having some risks of undertreatment, managed care offers the opportunity to shift the focus of care away from the traditional disease-based approach to one that emphasizes function and community-based care (see Chapter 62).

Since the early 1980s the hospice movement has helped people who are dying maintain a higher quality of life. Almost two-thirds of hospice patients are over age 65.19 By emphasizing patient-directed approaches to symptom control, even in those with no prospect for medical improvement, people can live more satisfying lives. The major objectives of care are pain control; prevention of constipation, depression, or other symptoms; involvement of families; and care at home. Medicare has recognized the benefits of this approach by funding hospice care since 1982. The family physician must be skillful in assessing the presence of suffering and providing appropriate interventions. Unfortunately, research indicates that as many as 46% of patients die in pain that could have been better controlled.20

Summary
Understanding the stages of life can help the family physician anticipate and explain common stresses experienced by patients. It is important to remember the great variability seen in individuals and the wide range of family types encountered in family practice. Because the burden of illness increases with old age, particular attention should be paid to viewing the experience of aging from the patient's perspective. After all, becoming old is the one "condition" we all hope to acquire, especially when one considers the alternative.

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