CARE OF ELDERLY- LESS IS BETTER

With increasing advances in science and technology, there has been considerable increase in life expectancy.
Not surprisingly, it has come at a cost; older adults are more prone to age-related diseases, functional impairment, and
physical inability. This would mean elderly usually have multiple medical problems, at times eventuating into
impoverished life. In 1978, psychiatrist Stephen Bergman published “The House of God,” under the pseudonym Samuel
Shem. It is a semi-autobiographical account of his medical internship in Boston in the early 1970s. It talks about better
care for elderly and demented patients by administering fewer tests and treatments, which seem to be contrary to what
one would think. It is described in the novel that an aggressive workup of an elderly, demented patient would rather have
an adverse outcome. This adage is still relevant today even after 4 decades. Research into use of dialysis in elderly
patients and its outcome suggests that, physicians must weigh the prospects for extending life against reduced quality of
life.

The issue of quality of life, euthanasia and helping patients to die with dignity has been debated. Some patients
with no real hope of a cure are often aggressively managed with medication and radiotherapy, which have significant
unpleasant and unendurable adverse effects. Cancer patients so treated may suffer from nausea and vomiting, ulceration
of mucous membranes, loss of hair, decreased immunity, and increased risk of infection. In cases of terminal cancer, one
could advocate for only symptomatic relief and advise patients and their families not to pursue aggressive management,
especially if families lack resources and finances, It may be a sensible and logical choice as often families exhaust all
their resources treating ‘incurable’ patients. However, this could instill guilt in survivors and mental health professionals
may have an important role in addressing it as well as the grief and a sense of helplessness and loss experienced by the
bereaved.

On 9 march 2018,in a landmark Judgment, the Five Judge Constitution Bench of the Supreme Court of India has
held that the right to life and liberty as envisaged under Article 21 of the Constitution is meaningless unless it
encompasses within its sphere individual dignity. The Bench also held that the right to live with dignity also includes the
smoothening of the process of dying in case of a terminally ill patient or a person in persistent vegetative state with no
hope of recovery.. There is a significant role for Psychiatrists once this happens. An intact mental status with retained
capacity is a pre-requisite for making such a decision. A psychiatrist will need to step in and assess capacity, if concerns
are raised regarding the person’s decision.

In addition to improving quality of life and helping with symptoms, palliative care can help patients understand
their choices for medical treatment. The organized services available through palliative care may be helpful to any older
person having a lot of general discomfort and disability very late in life.. In palliative care, one does not have to give up
treatment that might cure a serious illness. Palliative care can be provided along with curative treatment and may begin
at the time of diagnosis. The patient beginning hospice care understands that his or her illness is not responding to
medical attempts to cure it or to slow the disease’s progress. A mental health professionals presence is invaluable in the
palliative care setting. Careful assessment and timely identification of co-morbid mood disorder like depression,
cognitive difficulties or delirium in the elderly is of paramount importance. A judicious use of medicines and effective
psychotherapeutic approaches can bring about a significant improvement in the psychological status and improve the
quality of life in these individuals. Specific skills in Psychiatrists that may be of relevance include addressing sleep
difficulties, reducing agony and distress of pain using pharmacological and non-pharmacological approaches, identifying
end of life conflicts (ego integrity v/s despair as highlighted by Erikson) and grief work.

In his internationally well acclaimed book “ Being Mortal” Atul Gawande who is a surgeon in US, advocates for
the need to have more discussions on these areas which are shunned by many medical experts and mainstream media.
Mortality, an unavoidable endpoint, and the agony, ethics and legalities of it in the field of medicine are expertly
discussed from the point of view of the physician, patient and the relatives. It is important the we all remain open and
reflect along with the patient and relatives regarding the widening gap between expectations of cure and the reality of
death that we see with more and more advancements in the medical field and increasing longevity.