As a teaching practice, we take care of patients from other local care facilities who suffer from mental illness and have an acute medical illness. As I am on the hospital service for these two weeks, I am spending time with these patients as well as learning the habits of the physicians employed by these facilities. We have a patient with end stage dementia who has been bounced back and forth from our facility to their facility, a situation for which I feel bad. This patient has had a decline over the past 2 months, changing from a walking (though non-communicative) demented person to one who is now confined to the bed and no longer eating. While we have been trying to get the health care facility to acknowledge that the end of this person’s life is approaching, the facility continues to send her back for a “work-up” to see if we can make her “better.” It is my belief that the patient is the biggest loser in this case.   

As my Dad pointed out on this week’s (not often enough) phone call, we are all going to die of something. Dementia is not often a cause of death in our statistics but is often a contributor. People who are demented forget to eat, forget to drink, forget how to clothe themselves, forget how to walk, and once bed bound are likely to die of pneumonia. Despite this fairly predictable course, according to the Alzheimer’s Foundation in 2005 only 11% of people who were in a nursing home for dementia were refered to hospice and non-palliative care was quite common in residents with dementia. This included tube feeding, laboratory tests, restraints, and intravenous therapy.   

The Alzheimer’s Association identified the following as true regarding people living with dementia admitted into long-term care facilities:   

1. Aggressive medical treatment for residents with advanced dementia is often inappropriate for medical reasons, has a low rate of success, and can have negative outcomes that hasten functional decline and death.   

2. Quality palliative care is an effective alternative to aggressive treatment and is closely related to staffing and training in nursing homes.   

3. While there is an expanding body of knowledge about the risk and benefits of treatments for persons with advanced dementia, there are significant barriers to translating that knowledge to practice.   

#3 is especially true in the case of our patient.