The role of geriatric palliative care in hospitalized older adults

ABSTRACT

Take-Away Points:

1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.

2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.

3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.

KEYWORDS:

• Palliative care
• palliative medicine
• hospice care
• geriatric assessment
• health services for the aged
• hospital Medicine

Introduction

The specialty of palliative care has grown rapidly in the past 20 years and is now available to most patients in large hospital systems. Approximately 67% of hospitals with more than fifty beds have palliative care programs and 90% of hospital systems with over 300 beds now have access to palliative care [1]. The National Consensus Project for Quality Palliative Care (NCPQPC) defines palliative care as person- and family-centric care which attends to the physical, functional, psychological, practical, and spiritual consequences of serious illness and providing people living with serious illness relief from the symptoms and stress of their illness [2]. The NCPQPC identifies eight domains of palliative care (Table 1) [2].

Table 1. The national consensus project for quality palliative care’s eight domains of palliative care.

Domain of Palliative Care	Related Geriatric-Specific Concern
Structure and Processes of Care	Integrating hospital medicine, geriatrics, and palliative care teams in caring for hospitalized older adults with serious illness
Physical Aspects of Care	Performing adequate, geriatric-specific assessment of pain and developing an appropriate treatment plan
Psychological and Psychiatric Aspects of Care	Assisting the multidisciplinary team in differentiating depression and grief in older adults
Social Aspects of Care	Administering psychosocial interventions for seriously ill older patients and their families
Spiritual, Religious, and Existential Aspects of Care	Providing multidisciplinary spiritual care to older adults facing serious illnesses
Cultural Aspects of Care	Adjusting treatment plans to account for cultural considerations including age, illness, race, ethnicity, spiritual background, etc
Care of the Patient Nearing the End of Life	Facilitating generationally-appropriate legacy activities
Ethical and Legal Aspects of Care	Guiding seriously ill older adults and their families in advance care planning and generation of corresponding legal documents

Patients of any age and in any stage of serious illness are eligible to receive palliative care [2], although distinct patient populations can require different approaches [3]. At present, the majority of US patients receiving palliative care are over the age of 65 [4], and this population is expected to double by 2050 [5]. As the population continues to age, provision of high-quality geriatric medicine and palliative care will become an increasingly important requirement of the health care system [5], particularly as older adults’ hospitalizations account for 43% of all acute-care bed days in the United States [6]. While hospitalists remain on the front lines of providing high-quality primary palliative care, specialist geriatric palliative care requires integrating the two disciplines of geriatrics and palliative medicine in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses and supporting their families [7,8].

The unique features of caring for aging patients shape their palliative care requirements [9]. Geriatric patients have different needs than younger patients, including an increased need for assistance with medical decision making, increased focus on providing support to families and surrogate decision makers, and more time- and communication-intensive palliative care consultations [10]. Geriatric patients are more likely to receive palliative care consultation for dementia [10], are more likely to carry a non-cancer diagnosis [9], and are more likely to receive a recommendation to withhold or withdraw advanced life-sustaining treatments when compared to younger patients [10]. Older patients are also more likely to have palliative care consultation for end-of-life needs than younger patients [4]. Older adults have a different pattern of symptoms than younger patients, including increased frequency of anorexia [4], anxiety [4], and nausea [4], as well as different patterns and expressions of pain [11]. Lastly, these patients are more likely to discharge to hospice or a skilled nursing facility and less likely to discharge to home [9]. For these reasons, geriatric palliative care is a unique entity within the field of palliative care.

There are many barriers to providing high-quality palliative care to older patients. As a palliative care specialist shortage looms [12,13], increased collaboration between physicians who practice primary palliative care and palliative care specialists will be needed [14,15]. Hospitalists are often expected to provide palliative care but may not have formal training or comfort in doing so [16]. Confusion surrounding who should provide such care to aging patients, lack of cross-disciplinary understanding, distinct disciplinary identities, and lack of shared education and training limit collaboration between geriatricians and palliative care clinicians [17]. Both geriatrics and palliative care are less likely to receive institutional support [17] and are more likely to experience resource and staff shortages than other disciplines [18]. In addition, quality measures for palliative care are still being developed [19,20] and are not specific to geriatric palliative care.

The characteristics of aging patients can also limit high-quality palliative care. This population is less likely to have cancer, and patients with non-cancer diagnoses are less likely to receive timely palliative care consultation [21]. Prognostication is more challenging, as many patient models have significant limitations which preclude their use in older patients [22]. Older patients are also less likely to receive adequate pain control [23,24]. Hospitalized patients have a higher burden of palliative care needs than the general population [25]. Previous literature has posited that hospitalization following hip fracture is a sign of unmet geriatric palliative care needs and these patients have significant palliative care needs while hospitalized [26]. Furthermore, half of all inpatient palliative care consultations for aging patients occur within the first four days of hospitalization and a quarter of these patients die within four days of consultation [9]. These factors suggest that geriatric palliative care for hospitalized patients must remain a priority.

This literature review seeks to highlight the state of geriatric palliative care for hospitalized patients viewed through the lens of the eight domains of palliative care and suggests next steps for growth in individual practice patterns, institutions, and healthcare at large. One of the challenges facing this discipline is a relative paucity of literature that specifically addresses hospital-based geriatric palliative care across the domains of palliative care. As a result, this review includes some studies of outpatient and/or non-geriatric palliative care, in hopes that those lessons and conclusions can be applied to hospitalized older adults.

Review

Structure and processes of care

Palliative care can take many forms and be delivered in many different settings [2]. Regardless of setting, palliative care can be differentiated from other disciplines by the makeup of its interdisciplinary team, which includes physicians, advanced practice clinicians, nurses, pharmacists, chaplains, and social workers [2]. Hospitalized geriatric patients may interact with interdisciplinary teams via consultative palliative care, dedicated inpatient palliative care units, and/or inpatient hospice practices. Following dismissal from the hospital, interdisciplinary teams may provide palliative care to geriatric patients in the form of outpatient clinic-based palliative care, skilled nursing facility-based palliative care/hospice, or home palliative care/hospice.

Although the US palliative care movement initially focused on end-of-life care due to its origins in the hospice philosophy of care [27], it is now understood that palliative care can be appropriate at any point following diagnosis with a serious illness [28]. There is now increased attention to providing early and longitudinal palliative care with progressively increasing focus on symptom management and quality of life as illness-directed treatments become more toxic, less effective, and/or less concordant with patient goals [29–31]. Recent models of optimal palliative care integration emphasize referral at diagnosis, increasing presence as time progresses, and a shift in focus toward rehabilitation and survivorship care if a patient’s illness trajectory improves or toward end-of-life care and hospice referral if their trajectory declines [32]. The intensity of palliative care interventions that a patient may receive is a function of unmet needs within the domains of palliative care. These needs are often independent of the intensity of a patient’s illness-directed therapies.

Palliative care can be separated into primary palliative care and specialist palliative care (Table 2). Primary palliative care includes initial symptom management and routine conversations about prognosis, care goals, and code status. Areas and institutions lacking access to specialist palliative care can use primary palliative care to fulfill many of the routine needs of seriously ill patients [14]. In the hospital, primary palliative care is most often delivered by the hospital medicine and/or geriatrics team caring for the patient [33]. Professional organizations have called for development of structured competencies in primary palliative care [34] and standardization of these practices in caring for older patients [35]. A recent systematic review has called for additional study surrounding primary palliative care interventions to better understand their efficacy [36]. Education of hospitalists by palliative care specialists has been shown to be effective in improving hospitalist confidence in delivering primary palliative care [15,37].

Table 2. Examples of primary and specialist palliative care in hospitalized older patients.

	Symptom Management	Communication
Primary Palliative Care	Initial treatment of cancer-associated pain with short-acting opioid analgesics	Discussion of code status and identification of a preferred health care agent
Specialist Palliative Care	Treatment of severe cancer-associated pain with increasing doses of opioid analgesics, adjuvant medications, and/or procedural interventions	Navigation of complex family dynamics and differing perspectives on care goals/preferences

Specialist palliative care focuses on advanced symptom management and patient and family communication as an adjunct to primary palliative care [14]. Specialist palliative care can be delivered in a variety of ways in the hospital. The most widely available form in the United States is the hospital-based palliative care consulting model [25,38,39]. In-hospital palliative care consultation can assist with meeting the care needs described in this review while the primary hospital team continues to provide illness-directed therapy [40]. Despite the prevalence of both palliative care and geriatric [41] consulting teams in the United States, we are unaware of any formally integrated models for consultative geriatric-specific palliative care. Hospitalists are more likely to consult a specialist palliative care team when they feel that they need help clarifying care goals, would like additional time to communicate with patients and families, and reach the limits of their comfort with symptom management [42]. In hopes of standardizing care, clinically-triggered specialist palliative care consultations have also been studied and implemented in recent years [43–46].

Over the last 20 years, hospitals have increasingly adopted dedicated, specialist-run palliative care units for patients with advanced palliative care needs [47]. These units provide integrated palliative care as a primary service and often admit patients specifically for complex symptom management [48]. Hospital-based hospice teams may also provide palliative care with a specific focus on end-of-life care. Hospice patients in an acute care setting may be admitted for respite care or admitted under ‘general inpatient’ hospice status when complex symptoms require intensive monitoring and management that could not be provided in a different setting like home or a skilled nursing facility [49,50]. These delivery systems, plus outpatient clinic-, facility-, and home-based options, provide a continuum of care to meet a wide variety of patient and family needs.

Physical aspects of care

One of the foundational roles of the palliative care team is to provide comprehensive symptom assessment in seriously ill patients and offer recommendations for treatment [2,51]. Physical symptoms are often excellent predictors of hospitalization, healthcare utilization, and mortality in older adults [52,53]. Pain is especially difficult to assess and manage in geriatric patients [54]. Treatment of these patients’ physical symptoms can allow for better identification of other care needs that can be addressed by their health care team [55]. Palliative care consultation has been shown to improve physical symptom management resulting in higher care satisfaction, lower care costs, decreased length of stay, and decreased rates of readmission and ICU admission [56,57].

Geriatric patients experience different physical symptoms than younger patients, both in terms of prevalence and manifestations [4,11]. Robust symptom assessment is a particular challenge in older adults. The Edmonton Symptom Assessment Scale (ESAS) is a commonly-employed, standardized tool that measures physical symptoms including pain, fatigue, nausea, drowsiness, appetite, dyspnea, overall wellbeing, and other patient-reported symptoms. It also includes measurements of depression and anxiety [58]. ESAS has been widely validated [59,60], including in hospitalized older adults with cancer [61]. A modified ESAS has also been employed to assess symptom burden in geriatric outpatients with chronic illnesses [62]. Unfortunately, patients with cognitive impairment may be underserved by tools like ESAS, which fail to detect some symptoms in this population when compared to self and caregiver reporting [63]. Dementia-specific pain assessments are further limited by inconsistencies between tools [64]. Specialist palliative care teams receive dedicated training in advanced symptom assessment and can assist hospitalists and geriatricians in assessing pain.

Though physical symptoms are very common in older patients, little geriatric-specific evidence is available to directly inform guidelines for effective and safe management [65]. Previous studies have also demonstrated that geriatric patients experience barriers to receiving adequate pain control [23]. Underreporting of both the presence and severity of pain seems to be a major driver of poor pain control in older adults [66]. There is also a widespread perception that pain is a part of normal aging and not a symptom that requires assessment and management [67]. Older patients are also less likely to receive opioids for appropriate indications, including severe cancer-associated pain [24]. Dementia poses even greater challenges in achieving adequate analgesia, as these patients experience more pain and achieve worse pain control [66,68]. Clinicians are also more likely to conflate their pain with other non-pain symptoms [69]. Assessment of nausea and vomiting in older patients can be challenging due to the high frequency of serious, reversible etiologies. In this group, antiemetic choice and dosing must also be carefully considered due to increased risk of anticholinergic, central nervous system, and pro-arrhythmic side effects [70]. Palliative care teams specifically trained in advanced symptom management can assist hospitalists in providing effective and safe treatment recommendations for older patients.

Two special considerations in caring for older patients with serious illness are the geriatric syndromes of comorbidity (the presence of multiple medical diagnoses in a single patient [71]) and frailty (loss of strength, function, reserve, and endurance [72]). Older hospitalized patients with multiple medical comorbidities are at significantly higher risk of short- and long-term mortality compared to their non-comorbid counterparts [73]. Medical comorbidity predicts hospitalization in elderly patients residing in skilled facilities [74], is associated with more and worse symptoms, and correlates with decreased functional status [75]. Similarly, frail older inpatients demonstrate poorer prognosis overall, higher in-hospital mortality [76,77], longer length of stay [77], and other negative outcomes including falls, development of pressure ulcers, and development of delirium [78]. Frailty has been identified as its own serious illness and suggested as a trigger for palliative care consultation [79]. For these reasons, we anticipate that geriatric inpatients with comorbidity and/or frailty are more likely to have significant care needs amenable to palliative care involvement.

Psychological and psychiatric aspects of care

In addition to treating physical symptoms like pain and nausea, palliative care teams also address psychological and psychiatric problems, including mood disorders, anxiety, delirium, substance use disorders, and post-traumatic stress disorder [2]. A 2015 study of adults over 55 found that 11.4% and 6.8% of older adults have experienced depression and anxiety, respectively, in the preceding year [80]. The same study estimated that 3.8% experienced a substance use disorder. These problems are also prevalent in the patient population served by palliative care, as up to half of patients with a serious illness carry a comorbid psychiatric diagnosis [81,82]. Many clinicians express discomfort in treating depression in patients with serious illnesses [83]. In seriously ill patients, detecting psychiatric diagnoses in the context of normal grief and coping processes can be challenging [84], resulting to underdiagnosis and undertreatment [85].

Delirium is also extremely prevalent in hospitalized older adults, with an estimated 8-15% of palliative care patients affected [86]. Among specialized palliative care inpatient units and hospices, delirium is even more prevalent [87]. Hospital delirium is associated with many complications of hospitalization including length of stay, ICU transfer, persistent cognitive impairment, and mortality [88]. Adequate symptom assessment is substantially more challenging in delirious patients [89]. Delirium has a number of downstream effects on high-quality palliative care, as delirious episodes can cause significant patient and family distress [90] and limit patients’ ability to participate in their own medical decision-making [91]. Recent high-level data supports an ongoing role for reversal of factors provoking delirium, individualized supportive strategies including sleep preservation and reorientation, with time-limited antipsychotic-based pharmacotherapy limited to patients experiencing severe hyperactive delirium [92,93].

Palliative care interdisciplinary teams aid in identification and management of psychological and psychiatric needs [51]. Palliative care clinicians regularly assess their patients for depression [94]. Nurse-led palliative care interventions have been shown to reduce depressive symptoms in patients with cancer [95]. Palliative care-focused social workers are also trained to diagnose and intervene on psychological and psychiatric diagnoses [96]. Chaplains, who are frequently included in or consulted by a palliative care team, also provide emotional support to this patient population [97]. Palliative care interventions such as dignity therapy have been shown to reduce depressive symptoms in hospitalized patients [98]. In addition, the support and communication offered by a palliative care team may prevent depressive symptoms [51]. If needed, palliative care teams may refer to external mental health professionals, including psychiatrists and psychologists, in order to best manage patients’ emotional health concerns [99]. Consequently, palliative care teams may be able to better address psychological and psychiatric issues which arise in the care of older hospitalized patients.

Social aspects of care

The interdisciplinary palliative care team is integral to providing quality social care [100]. While some of this care comes from physicians, advanced practice clinicians, nurses, and chaplains, social workers are generally specifically tasked with comprehensive social evaluation, family assessment, providing counseling therapies including cognitive-behavioral therapy and dignity therapy, developing care plans that include social services, and navigating the health care system [2,96,100]. Dedicated palliative care social workers have been shown to improve patients’ access to appropriate social services [101], and social services interventions decrease hospitalization, skilled nursing facility admission, and falls [102].

Assessment and care of the family is an essential component of palliative social care [2]. When loved ones are seriously ill, their families experience anxious and depressive symptoms, demoralization, and anticipatory grief [103]. Family caregivers are even at increased risk of becoming physically ill themselves [104]. Care of the family can come from any member of the palliative interdisciplinary team, but specialized interventions often fall to specific professionals like social workers [2,96]. Bereavement support is a key feature of family care, and is discussed in ‘Care of the Patient Nearing the End of Life’ below.

The goal of social care interventions is to improve social support, which benefits older patients in a variety of ways. Better social engagement is associated with better subjective wellbeing [105], quality of life [106,107], and better physical function [102]. Conversely, older patients who experience subjective social isolation tend to suffer from increased mortality [108], more depressive symptoms, and increased psychosocial distress [109]. New evidence also suggests that social isolation may be associated with pre-clinical markers of Alzheimer-type dementia [110]. More research on palliative care-specific social intervention is needed to further understand their role in the care of patients with serious illnesses [2,111].

Spiritual, religious, and existential aspects of care

Delivery of spiritual care is a key role of the interdisciplinary palliative care team [2] and spiritual care is a necessary part of geriatric palliative care [112]. Hospitalized geriatric patients tend to be religious; a 1998 study of hospitalized patients over age 60 found that more than half prayed daily and/or attended religious services weekly, 85% held intrinsic religious beliefs, and nearly half spontaneously reported that faith was the most important factor in coping with health issues [113]. Similarly, patients receiving palliative care consultation are very likely to be spiritual and/or religious [114]. Unfortunately, an overwhelming majority of patients do not receive spiritual care, even when they have a life-limiting diagnosis [115].

Spiritual and religious health is an important factor in overall health. In older patients, both religiousness and spirituality predict social support and physical functioning and are associated with fewer depressive symptoms, better cognitive function, and improved cooperativeness [116]. Religious activity attendance of any frequency has also been associated with decreased emotional distress [117]. Positive religious coping and improved physical health appear to be associated [118]. Conversely, negative religious coping is associated with distress, confusion, depression, negative physical and emotional well-being, and poor quality of life [114].

Spiritual care can be provided by any member of a palliative care interdisciplinary team [2]. Traditionally, chaplains have been integral in providing spiritual care to hospitalized patients [119], but only a small proportion of chaplain discussions explicitly center around religion [120]. Hospitalized patients express the desire to visit with chaplains and find those visits to be valuable [121]. At the same time, many patients desire spiritual care from their physicians and nurses. A 2012 study found that 87% of physicians and 86% of nurses feel that spiritual care is important. Unfortunately, physicians rarely (6%) provide spiritual care to patients, which was tied to lack of training and expertise [115]. Engagement of a palliative care team with training and comfort in assessing spiritual health provides an opportunity to address this patient care need [122].

Cultural aspects of care

Another charge of the palliative interdisciplinary team is to provide care that is aware of, respects, and aligns with a patient’s cultural values [2]. Culture is a complex social structure informed by a number of factors which confers upon its participants sets of beliefs, values, expectations, responsibilities, practices, lifestyles, and opportunities [123]. Membership to certain cultural groups, especially minority races and ethnicities, carries risk of healthcare disparities [124,125] including end-of-life care and hospice [126]. Developing and practicing cultural curiosity in healthcare has been suggested as a major strategy to reduce disparities in American health care [127,128].

Geriatrics research increasingly recognizes that aging patients’ culture impacts the care that they receive [129]. In fact, age itself has been shown to be a significant contributor to patient culture, shaping both patients’ cultural identities and their health care [130]. Living with illnesses of aging such as dementia [131] and cancer [132] often shapes a patient’s cultural identity [133]. Geriatric patients are more likely to have cultural differences from their hospital care teams as a result. Patients feel that cultural issues are a significant barrier to receiving high-quality end-of-life care [134], and culturally-distinct populations require a basis of trust to establish effective health care relationships [135], further highlighting the importance of involving specialists who can attend to cultural needs. Of particular importance for the geriatric palliative care population, cultural factors become an even more significant part of providing quality care in patients with serious illness and at the end of life [3].

A comprehensive palliative care assessment should include a cultural assessment [2], for which a number of best practices have been identified, including cultural respect, person-centered communication, presence and time, and discussion of what gives life meaning [130,136]. A number of structured frameworks have been developed to allow palliative care teams to optimally convey cultural respect [137,138] and communicate both verbally and non-verbally in a person-centered fashion [139]. The palliative care interdisciplinary team plays a role in providing cultural care [2], as patients often discuss meaning during hospital chaplain visits [120], and social workers may provide cultural assessments [96].

Culture often informs patients’ goals, values, and preferences surrounding the end of life [3]. A 2019 Australian study of geriatric inpatient rehabilitation patients cultural needs are not always recognized or facilitated at the end of life, and that clinicians are often unaware of patients’ cultural needs. Clinician participants in this study also sought more education regarding cultural needs and felt that dedicated discussion of cultural issues is necessary to provide quality patient care [140]. There are a number of culturally-distinct populations in palliative care who have unique needs in aging, serious illness, and at the end of life, including patients of minority race or ethnicity [3,139,141], patients who have immigrated from other countries [142], patients with physical [143] and intellectual disabilities [144], patients belonging to the LGBTQIA community [145–147], and international patients who travel for their care [137,148,149]. Collaboration with a palliative care team can allow for more robust exploration of culture and attention to subsequently-identified issues in older patients.

Care of the patient nearing the end of life

One of the most widely-recognized roles of the palliative care team is in providing care to patients nearing the end of life [150]. In the US, this care is often delivered in the hospital [151]. Hospitalized patients feel that quality communication, adequate symptom management, respect and compassion, expert-level care, and the respect of their care team are the most important aspects of receiving end-of-life care [152,153]. Palliative care interventions have been demonstrated to improve health care utilization and end-of-life care quality measures in a number of randomized trials [154]. In-hospital consultative palliative care teams have specifically been shown to improve patient and family satisfaction and cost of care [57]. Transfer of inpatients to a dedicated, specialist-run palliative care unit may also reduce end-of-life care costs [48] while maintaining high care satisfaction [155]. This effect is not specific to inpatient practice, as early outpatient palliative care referral may also increase the quality of end-of-life care [156].

Palliative care teams provide a number of unique services to patients nearing the end of life. Legacy work or activities designed to create tangible items in the process of life review, like scrapbooks and audio recordings [157], can be facilitated by the palliative care interdisciplinary team [2]. This is an important option for older patients, as leaving a tangible legacy is a strategy that geriatric patients use to foster hope [158]. Palliative care teams can also provide dedicated assistance with culturally related end-of-life needs such as facilitating specific customs to honor a deceased loved one [137,139]. Palliative care teams assist with hospice enrollment; patients receiving consultative palliative care in-hospital demonstrate longer hospice lengths of stay [57]. Furthermore, specialist palliative care involvement can facilitate advanced management techniques such as palliative sedation for refractory symptoms [159].

Another role of the palliative care team is to provide bereavement support to patients and their families as they approach the end of life [2]. The importance of this critical support is highlighted by the recent finding that bereaved individuals have increased healthcare utilization and increased risk of death following loss of a partner [160,161]. In particular, unexpected partner death carries higher risk of mortality among aging individuals [162]. Different grief structures have been proposed in older bereaved spouses, with individual grief patterns correlating with complicated grief, depressive symptoms, and quality of life [163]. Older bereaved adults are more likely to be prescribed anxiolytics or antidepressants compared to matched controls [164]. Bereavement in dementia caregivers appears to be a unique entity characterized by anticipatory grief and higher rates of anxiety and depression, though these may be improved with hospice care and structured bereavement support [165].

There are many diverse frameworks for providing bereavement support [166], but this resource remains underutilized [167]. Fortunately, bereavement support use appears to be higher in family members at highest risk of bereavement-related psychiatric issues [167]. Interview-based research suggests that older adults’ bereavement care is improved with longitudinal relationships, is dependent on an individual’s readiness to approach bereavement, and is limited by variable follow-up [168]. Palliative care team interventions have been shown to improve the grief and bereavement experiences for caregivers and surviving family [111].

Ethical and legal aspects of care

Lastly, palliative care teams can assist with the unique medicolegal [169] and ethical [170] issues that arise in the care of aging patients with serious illnesses. Palliative care teams are frequently involved in cases that demonstrate complex ethical or legal aspects including questions of autonomy, substituted judgment and surrogate decision-making, truth-telling and information disclosure, withholding or discontinuing treatment, artificial nutrition and hydration, and perceived futility of care [171–173]. Up to a third of patients receiving clinical ethics consultations have also received palliative care consultations [174]. Palliative care team members are expected to achieve and maintain competency in dealing with these issues [2]. Some palliative care teams have integrated legal counsel for patients and families, and have shown efficacy in estate planning, custody issues, guardianship, legal advice, generation of legal documents, and social services advocacy [175,176].

There is a significant literature base surrounding the role of palliative care teams in advance care planning [111,177]. This is of critical importance in older patients, as a majority of patients over age 80 have thought about their end-of-life care, but less than half complete an advance care plan [178]. Patients with dementia demonstrate similarly low rates of advance care plan completion [179,180]. Perhaps more importantly, concordance between patients’ stated wishes and the electronic medical record only occurs 30% of the time [178]. Another study showed that many seriously ill inpatients do not have adequate conversations regarding code status at hospital admission [181]. Randomized data shows that facilitating advance care planning with aging patients increases the likelihood of receiving goal-concordant care and decreases family depression, anxiety, and stress [182]. In older patients, key aspects of advance care planning include identification of surrogate decision makers and exploring and documenting goals, values, and preferences [183,184].

Implications for practice

Many opportunities exist for better provision of palliative care to the geriatric population. Hospitalists are often on the front line of caring for seriously ill older patients, and may be an optimal connector to palliative care services [16,25]. Hospital medicine clinicians are also the providers of primary palliative care- the day-to-day care of seriously ill older adults and patients with unmet palliative care needs [14,185]. Consequently, it is critical for hospitalists to maintain basic skills in pain and symptom control and patient communication. Palliative medicine specialists can be a fundamental part of this continuing education [185,186]. One recent pilot study showed that communication training by palliative care physicians improved hospitalists’ skill in discussing goals of care and improved patient outcomes as well [187]. When patient needs become complex enough to require specialist intervention, palliative care interdisciplinary teams can provide additional support, including advanced symptom management recommendations, facilitation of complex care conferences, dedicated assessment and care of spiritual and cultural needs, transition to expert end-of-life care, and assistance with ethically and legally complex situations [25,185]. Continued cross-professional education between hospital medicine and palliative care teams will help geriatric patients receive better care.

Another opportunity to improve palliative care provided to older patients is closer integration of the practice of hospital medicine, geriatrics, and palliative care [186]. Interprofessional rounding has been shown to increase use of hospital palliative care consultation, improve communication between teams, and improve hospitalist confidence in their own palliative care skills [188]. Geriatrics-specific hospital care models like Acute Care of the Elderly (ACE) units have shown promise in caring for older adults [189,190]. Geriatrics teams also improve outcomes by tailoring care plans to older patients’ needs, expertise in safe and effective transitions out of the hospital, and providing high-quality communication to patients and families [191]. Based on these successes, we are hopeful that similar processes, such as supporting palliative care-trained hospitalists and geriatricians, co-management of seriously ill hospitalized patients between the three disciplines, interdisciplinary rounding, or even direct introduction of dedicated palliative care into ACE units can improve the care of older adults.

Finally, as national and international efforts are undertaken to further refine palliative care delivery for geriatric patients, it is important to recognize how this literature can influence the day-to-day practice of general hospital medicine. While ample literature exists to inform palliative care use and integration at large, only a handful of studies have specifically described geriatric palliative care and its impact on patient outcomes. A number of related clinical trials are underway to fill this void. One multicenter American study aims to evaluate the efficacy of structured advance care planning interventions in older patients with cancer [192]. Another is piloting structured, multidisciplinary collaboration between oncologists, geriatricians, palliative care specialists to improve quality of life, symptom control, and function in older patients [193]. A recently-completed European study of advanced dementia patients is evaluating a decision-making aid’s effect on caregivers’ understanding of palliative care and hospice [194]. Other trials seek to assess palliative care in elderly patients with hematologic malignancies [195,196]. None of these studies, however, are specific to inpatients. One American trial is currently enrolling and aims to evaluate an artificial intelligence tool to predict the need for specialist palliative care consultation during hospitalization [197]. A Singaporean study is evaluating palliative care and oncology co-rounding in hospitalized older adults being treated for cancer [198].

Despite these efforts, more research is needed. Geriatric patients have unique needs that differentiate their care from younger adults; these data suggest that their palliative care needs are different as well. Palliative care is appropriate for any geriatric patient with a serious illness, regardless of prognosis or proximity to the end of life, and palliative care interdisciplinary teams can provide a wide variety of services to meet needs across the eight domains of palliative care.

Declaration of interest

The authors have no conflicts of interest to disclose.

The contents of the paper and the opinions expressed within are those of the authors, and it was the decision of the authors to submit the manuscript for publication.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.