Palliative and Therapeutic Harmonization: A Model for Appropriate Decision‐Making in Frail Older Adults

Abstract

Frail older adults face increasingly complex decisions regarding medical care. The Palliative and Therapeutic Harmonization (PATH) model provides a structured approach that places frailty at the forefront of medical and surgical decision-making in older adults. Preliminary data from the first 150 individuals completing the PATH program shows that the population served is frail (mean Clinical Frailty Score = 6.3), has multiple comorbidities (mean 8), and takes many medications (mean = 9). Ninety-two percent of participants were able to complete decision-making for an average of three current or projected health issues, most often (76.7%) with the help of a substitute decision-maker (SDM). Decisions to proceed with scheduled medical or surgical interventions correlated with baseline frailty level and dementia stage, with participants with a greater degree of frailty (odds ratio (OR) = 3.41, 95% confidence interval (CI) = 1.39-8.38) or more-advanced stage of dementia (OR = 1.66, 95% CI = 1.06-2.65) being more likely to choose less-aggressive treatment options. Although the PATH model is in the development stage, further evaluation is ongoing, including a qualitative analysis of the SDM experience of PATH and an assessment of the effectiveness of PATH in long-term care. The results of these studies will inform the design of a larger randomized controlled trial.

Janus at the Crossroads: Perspectives on Long-term Care Trajectories for Older Women With Dementia in a Canadian Context

“…Her family noted, "We had little information about where she was at with her dementia and, with the added diagnosis of lung cancer, we felt overwhelmed when thinking about what her likely prognosis and journey would be given both of these conditions" (Sheila's story). Although health status is commonly linked to heightened frailty and increased vulnerability to poor transitions, there is limited research on the specific ways that comorbidity interacts with other contextual factors to influence trajectories and quality of life (Chen, Chan, Kiely, Morris, & Mitchell, 2007;Kellett, Moyle, McAllister, King, & Gallagher, 2010;Moorhouse & Mallery, 2012;Sivananthan, 2015;Wysocki et al, 2014).…”

“…The health of an individual with dementia on the LTC trajectory from home into nursing home care tends to be characterized as one of progressive disability in terms of cognitive and physical functioning (Moorhouse & Mallery, 2012). At the same time, the pace of change can be much slower compared to those with other life-threatening illnesses such as cancer or heart failure (Moorhouse & Mallery, 2012), leading some researchers to suggest that persons with dementia represent a distinct subgroup with unique service requirements (Covinsky, Eng, Lui, Sands, & Yaffe, 2003;Kane & West, 2005).…”

“…At the same time, the pace of change can be much slower compared to those with other life-threatening illnesses such as cancer or heart failure (Moorhouse & Mallery, 2012), leading some researchers to suggest that persons with dementia represent a distinct subgroup with unique service requirements (Covinsky, Eng, Lui, Sands, & Yaffe, 2003;Kane & West, 2005). For some, the slower pace of change can make it harder to recognize their palliative status, thereby restricting access to specialized, end-oflife services when needed (Covinsky et al, 2003).…”

Promoting higher blood pressure targets for frail older adults: A consensus guideline from Canada

“…7,12 The Frailty Assessment for Care-planning Tool (FACT) uses scaling compatible with the Clinical Frailty Scale but has been developed for use as a practical and interpretable frailty screening tool for nonexperts (TABLE 1). The FACT assesses cognition, mobility, function, and the social situation, using a How we developed the guideline To improve awareness of frailty when making treatment decisions and to develop specific recommendations for treating hypertension in the frail elderly, two groups came together-PATH 27,28 and Dalhousie ADS. 29 The Palliative and Therapeutic Harmonization program…”

“…The PATH program 27,28 aims to help health professionals, patients, and families consider frailty when making treatment decisions. In a series of three steps, patients referred to PATH undergo a comprehensive assessment of frailty and health status (step 1), receive information about the findings of the assessment (step 2), and engage in a discussion about treatment options (step 3).…”