Death and dying: management of patients with end-stage disease.

The culture of nursing homes historically has been rehabilitative. This approach has been enforced by the Omnibus Budget Reconciliation Act (1987) regulations, which focus on "decline" as largely avoidable. With the passage of the Prospective Payment System, nursing homes have become increasingly a site of death. In the same way that no sharp transition exists between living and dying, no sharp transition exists between life-prolonging, disease-specific therapy and palliative therapy. Life-prolonging therapy can lead to symptoms that require palliation, and, in some instances, (e.g., end-stage heart failure) life-prolonging therapy and palliative therapy may be indistinguishable. Palliative care, with the control of symptoms, relief of suffering, and promotion of quality of life, is appropriate to all stages of disease, with an increasing proportion of palliative care relative to curative therapy as the disease progresses. The goals of symptom management and attention to potential sources of suffering in palliative care are components of quality end-of-life care and are discussed.

A skin lesion found by serendipity.

A 77-year-old retired postal worker presented with symptoms of recurrent aspiration pneumonia, for which he had last been seen one month earlier. Oropharyngeal dysfunction, presumably caused by previous strokes, was demonstrated by video-esophagoscopy, and a percutaneous gastrostomy tube was placed at that time.

Chronic pain: primary care treatment of the older patient.

The prevalence of chronic diseases associated with pain increases with age, and pain prevalence appears to increase with the level of functional dependence. Chronic pain in older patients is associated with sleep disorders, impaired physical and social function, and increased healthcare utilization. Symptoms of pain, anxiety, and depression are often associated and may intensify each other. Because a complete resolution of chronic pain is unlikely, it is important to establish early in therapy the level of pain that the patient would find acceptable. The goal of therapy is to treat chronic pain while minimizing side effects and optimizing the patient's functional status.

Advances in hospice care.

Hospice care developed in part as a reaction to the impersonal and technology-dependent end-of-life care offered by modern medicine. Unique approaches to care that emphasize interdisciplinary team management of troublesome symptoms and the promotion of quality of life as defined by the patient, are finding their way into all aspects of health care. Symptom control measures have expanded to include chemotherapy, radiation therapy, and multimodal therapies. Both the development of a unique knowledge base and advances in research have fostered the integration of hospice and palliative care into mainstream medicine.