End-of-life issues

In reply: We agree with Kurrle about the importance of encouraging patients to prepare for future medical decision-making. The strategies she suggests are practical and useful. However, we believe that the difficulties confronting physicians in caring for older patients require us to go further and to rethink what represents excellent care at the end of life. Today, death from acute illness has largely been superseded by death from chronic illness, and the latter generally follows one of three main trajectories: cancer, organ system failure or dementia/frailty.1 Our systems of care for people who are near the end of life need to reflect the ways in which elderly people actually decline and die. If we wish to promise elderly people what a decent society should be able to promise them (accurate diagnoses, excellent control of symptoms, the absence of any gaps in care and of any "surprises" in their condition and its treatment, clarity about the role of their family in caring for them, a way of dying that accords with their hopes, and, most importantly, help to live the remaining part of their lives "to the full"), we need to rethink the care provided during hospitalisation of older people at the end of their lives.1