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I just read Chris Feudtner’s brief piece, “The Breadth of Hopes,” in the New England Journal.  Among other things, the article helps me articulate a difference between care at the end of life (last years, months, days) for many older people and care at the end of life for younger people. The distinguishing characteristic here is whether or not an individual has seen death coming, even distantly, and processed that, even a bit. Not all older people have done so, but many have – I think of the patient in David Reuben’s recent JAMA paper who said, “When you’re 83, it’s not going to be 20 years.” And many families have come to a similar point when an older family member develops a life-threatening illness. In contrast, few younger people come to such a point before developing a serious illness. As one of my colleagues says, in geriatrics, our patients are nearer the end than the beginning, and they generally know that. This is not the case for younger people, and in our society, probably never the case for a parent with a previously healthy child.

I wonder if this difference might account for some of the cultural distance between geriatrics and palliative medicine, when such distance exists. Geriatricians may think, I do care at the end of life for many patients, and I do it well. Palliative medicine specialists may think, even geriatricians who provide great care at the end of life just don’t get an important part of palliative medicine, caring for people who won’t live a “natural lifespan,” who have had their hope for a long life dashed, and yet you may still hope for a miracle.

Does this resonate?

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