Navigating Healthcare in the Frail Elderly Amidst a Sea Of Change and a Fragmented Care System

by Vanessa Mandal, MD

With the aging of our population, by 2035 the elderly population will outnumber children for the first time in U.S. history. This change in demographics, coupled with the accelerated changes in health care delivery, poses significant challenges for health care providers managing patients with complex chronic illnesses. The shift from fee-for-service to value-based care adds even more complexity. The Saturday May 20th afternoon session brings together a panel of speakers who will present a person-centered approach to providing quality of care near the end of life. End-of-life care entails conversations where providers have to address prognosis, and shared decision making.

Dr. Lisa Seo, a palliative care physician with Dignity Health in Northern California, will present perspective on palliative care in patients with cancer and non-cancer diagnoses. She is currently involved in a palliative care initiative at Manor Care, on opening conversations to address the bigger picture of goals of care near the end of life. The focus of her conversations are on the patient’s wishes as they weigh options of ongoing medical interventions with wishes for care that minimizes pain and suffering.

Dr. Paul Schneider, of the Los Angeles VA Medical Center and chair of the Southern California Bioethics Committee Consortium, will address informed consent in decisions to convert goals to a comfort-based approach, especially difficult in patients who have limited or no medical decision-making capacity. Providers need to facilitate individuals participation in advance care planning and shared decision making. The care of the “unbefriended patient” and the ethical principle of beneficence require that the physician leading the team display the utmost care and compassion when risks and benefits of medical interventions including PEG tube feedings, hemodialysis, chemotherapy, defibrillator placement and other high risk medical treatment are considered.

Leah Morris NP, a member of the Coalition for Compassionate Care of California and a longtime hospice nurse practitioner, has been involved in a home-based palliative care initiative in Northern California. This is a unique position as she brings a skill set of managing patients who do not yet qualify for hospice benefits. She will discuss policies regarding palliative care initiatives and will share challenges she has faced as a home-based palliative care clinician dealing with patients who were not able to navigate the structural barriers of access to care, fragmented care, and limited support systems.

Cindy Keenan, with Sojourn Hospice, will bring the lens of the hospice benefit, including the role of non-clinical members in providing physical, psychological, and spiritual support for those patients and families. Cindy will answer frequently asked questions about the services covered under the Medicare hospice benefit, including post bereavement supportive care for families.

Key elements of a conversation on comfort measures are assessing decision making capacity, addressing prognosis, and care planning that optimizes social, psychological and spiritual support at the end of life. Dr. Vanessa Mandal, Geriatrician with Dignity Health, will present two cases, the first involving a request from a patient with end-stage Parkinson’s to discontinue tube feeding and the second about a patient with moderate dementia who wanted to discontinue hemodialysis.

This CALTCM session is very relevant to post-acute and long-term care providers now, especially in the context of the Epple Bill (HSC 1418.8) where medico-legal decision making rests on the interdisciplinary team. We invite you to share your stories with our panel and gather tools to help you provide person-centered care as you parse the POLST into a more meaningful conversation.

More information and registration available online at: