REVIEW

CURRENT
OPINION Palliative and end-of-life care for the older adult
with cancer
Lise Huynh and Jennifer Moore

Purpose of review
Despite established benefits of palliative care in the oncology population, it remains an underutilized
resource particularly among older adults. The illness trajectory and needs of an older adult with cancer are
unique. The purpose of this paper is to review the current literature on providing comprehensive palliative
and end-of-life care for the older adult with cancer.
Recent findings
Though the difficulties of applying traditional palliative care principles in the older patients with cancer
have been discussed, this review reveals a clear gap in the literature in discussing the provision of
comprehensive palliative and end-of-life care in this population. Very few articles have been published in
this domain with even fewer published within the past 18 months.
Summary
As such, this article reviews key aspects of palliative and geriatric medicine that need to be considered and
integrated in order to provide comprehensive palliative care to the older adult with cancer. This includes a
discussion of proper pain and symptoms assessment, performance status assessment, advance care
planning, and end-of-life care while considering the nuances of geriatric syndromes.
Keywords
end-of-life care, geriatrics, older adult, oncology, palliative care

INTRODUCTION of shared training and collaboration between geria-

&

The benefits of early palliative care involvement in
the oncology population have been well estab-
lished. Palliative care is interdisciplinary care
focused on the relief of suffering and achieving
the best possible quality of life. Defined by the
WHO as ’an approach that improves the quality of
life of patients (adults and children) and their
families who are facing problems associated with
life-threatening illness’, palliative care ’prevents
tricians and palliative care clinicians [3 ]. These
obstacles are accentuated when the older adult
patient also has a malignant diagnosis, with the
involvement of an additional medical team who
may be unaware of the particular palliative needs
in the older population. Indeed, the palliative care
needs of the older adult with cancer are unique and
our recent search reveals that there is a paucity of
literature on how to integrate high-quality geriatric
&

and relieves suffering through the early identifica- and palliative, end-of-life care [3 ,4–6]. Little has
tion, correct assessment and treatment of pain and been published to date on this topic with only three
other problems, whether physical, psychosocial or articles published within the last 18 months
& & &

spiritual [1].’ Recent studies have found early [3 ,12 ,25 ].

palliative care involvement to improve patients
and families’ quality of life, decrease acute care
utilization, and in certain cases, improve survival
[2].
Despite its known advantages, palliative care
remains an underutilized resource, particularly in
older adults. The current literature has examined
barriers to access to Palliative care for this popula-
tion. Established provider-related barriers include a
lack of cross-disciplinary understanding and a lack
Division of Palliative Care, Sunnybrook Health Sciences Centre, Toronto,
Ontario, Canada
Correspondence to Lise Huynh, MD CCFP (PC), Palliative Care Physi-
cian, Sunnybrook Health Sciences Centre, Division of Palliative Care, H-
336, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada.
Tel: +1 416 480 6100 x 7255; e-mail: lise.huynh@sunnybrook.ca
Curr Opin Support Palliat Care 2021, 15:23–28
DOI:10.1097/SPC.0000000000000541

1751-4258 Copyright ß 2021 Wolters Kluwer Health, Inc. All rights reserved. www.supportiveandpalliativecare.com

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

Geriatric oncology
KEY POINTS
 There is a paucity of literature in guiding the clinician
to provide comprehensive palliative and end-of-life care
for the older adult with cancer.
 Though there are currently no clear clinical guidelines
in assessing symptoms and prognosis in this
population, use of validated pain and symptoms
management tools in the context of cognitive
impairment and use of validated performance status
tools although taking into consideration geriatric
syndromes are warranted.
 The clinician providing palliative care must be
cognizant of cognitive, biopsychosocial, and cultural
barriers while engaging in early and iterative Advance
Care Planning conversations.
 Little is published and there is a need for additional
clinical guidance on how to engage effectively in
Advance Care Planning conversations to
comprehensively address the unique needs of the older
adult with cancer.
 At the end-of-life, terminal trajectories, caregiver
burden, and subsequent grief and bereavement for the
older oncology patient and family are unique.
The typical trajectory of illness in an older adult
with cancer may differ widely from a younger oncol-
ogy patient [4]. Treatment of the older adult’s cancer
involves not only treating the primary disease, but
also managing the higher likelihood of potential
comorbidities and presence of geriatric syndromes,
while assessing and treating physical and psycho-
logical symptom distress and establishing treatment
plans and goals of care. Additionally, the needs of
the caregiver of an older patient with cancer will
differ from the needs of the caregiver of younger
patients, providing new challenges to the healthcare
team. Caregivers for older patients are often adult
children with their own family, work responsibili-
ties and may have their own personal health issues.
The older adult with cancer may also be a caregiver
for another individual in need whose care will need
to be coordinated as the patient in question
becomes increasingly ill.
Therefore to provide comprehensive palliative
care to this patient population, clinicians need to be
aware of the intersections between geriatric medi-
cine and palliative care in order to recognize and
address pain and symptoms commonly seen in pal-
liative care, while also being aware of common
geriatric syndromes and the unique prescribing
and assessment difficulties in this population.
Few physicians and clinical teams have been
trained in how to manage these complex situations.
24 www.supportiveandpalliativecare.com
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
However, with careful planning and collaboration, a
comprehensive patient-centered care plan that
addresses both physical and psychosocial needs
can be developed. This article aims to improve pal-
liative and end of life care for the older adult with
cancer by addressing:
(1) Assessment of pain and symptoms.
(2) Challenges in performance status assessment
and prognosistication.
(3) Advance care planning.
(4) End-of-life care.
Assessment of pain and symptoms in the
older adult with cancer
Integral in the provision of comprehensive pallia-
tive care is the proper assessment of pain and other
symptoms. Use of the Edmonton Symptoms Assess-
ment Score (ESAS) has become an established vali-
dated standard for palliative care symptoms
assessment in Oncology. Originally developed by
Bruera et al. as a clinical tool to document symptoms
in patients with advanced cancer admitted to a
palliative care unit, the ESAS consists of an 11 points
numeric rating scale to assess common symptoms
including pain, tiredness, drowsiness, nausea, lack
of appetite, shortness of breath, depression, anxiety,
and well-being (Appendix 1, http://links.lww.com/
COSPC/A25) [7]. Although validated in the context
of oncology patients admitted to a palliative care
unit and translated across multiple different lan-
guages, the ESAS tool has not been adapted for
use in the older adult. The ESAS has also been
criticized to be reliant on patient self-report as well
as having a focus on physical symptoms [8], aspects
that may resonate less with providers with a geri-
atrics focus of practice. Seldomly used in the pallia-
tive care field are objective tools often used in the
geriatric assessment to determine pain and symp-
toms assessment in the context of cognitive
impairment. These include the Pain Assessment in
Advanced Dementia (PAINAD) scale (Appendix 2,
http://links.lww.com/COSPC/A26) and the Pain
Assessment Checklist For Seniors with Limited Abil-
ity to Communicate (PACSLAC) tool [9,10]. The
PAINAD scale is more commonly used, as its results
are on a 0–10 rating scale, consistent with the
common rating scales in the general population.
However, the PACSLAC tool may provide a more
comprehensive pain assessment as it evaluates the
six critical domains of common pain behaviors in
cognitively impaired persons as identified by the
American Geriatric Society Panel in 2002.
Volume 15  Number 1  March 2021
 End-of-life care for the older adult with cancer Huynh and Moore
The impact of under-recognition and subse-
quent undertreatment of pain in the older adult
are numerous. Depression, anxiety, decreased
socialization, sleep disturbance, worsening cogni-
tion, impaired ambulation, and increased health-
care utilization and costs have all be found to be
associated with the presence of persistent pain in the
older adult. There is also the concern of slower
rehabilitation, worsened cognition, delirium, and
adverse effects of polypharmacy in this patient pop-
&
ulation [11,12 ,13–15]. This paper focuses on the
assessment of pain and symptoms in the older adult
with cancer and as such, the management of pain
and symptoms in this population will not be dis-
cussed. Similar considerations need to be taken
into account while managing pain and symptoms,
however, and this has been discussed in the litera-
ture. Important points to consider include the
importance of multimodal pain and symptoms
management, engagement with interventional
and oncology teams, as well as paying particular
attention to geriatric syndromes such as falls, delir-
&
ium, and polypharmacy [12 ,13–15].
Although there currently exists no validated
tool for comprehensive pain and symptoms assess-
ment in the older patient with cancer, routine refer-
ral to the above-mentioned tools while assessing the
older adult for pain and other symptoms would
be warranted.
Performance status assessment and
prognosis
Instrumental in the provision of palliative care for
oncology patients is the determination of a patient’s
performance status and this has been correlated to
prognosis. The Palliative Performance Scale (PPS) is a
validated tool widely used by palliative care pro-
viders to determine performance status [16–18].
The PPS is a performance scale that incorporates
five observer-rated parameters: ambulation, activity,
evidence of disease, self-care, intake, and level of
consciousness. It has 10 categories ranging from 10
to 100; higher scores indicate greater functioning
(Appendix 3, http://links.lww.com/COSPC/A27). It
provides a mechanism for monitoring physical dete-
rioration and is used to aid communication, prog-
nostication, and treatment decision-making [16].
The PPS is a well-validated tool in palliative medi-
cine and has been correlated with other commonly
used performance status tools including the Karnof-
sky Performance Status (KPS) and the Eastern Coop-
erative Oncology Group (ECOG) [19–22].
The association between performance status (as
measured by PPS, ECOG, or KPS) and survival has
been clearly established within the oncology and
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Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
palliative care literature. Performance status is found
to be a key component in numerous prognostic
models and performance status alone, as measured
by PPS has also been found to be a reliable predictor
of prognosis in both the inpatient and outpatient
palliative care settings for an individual within their
last 90 days of life [19–22].
Though traditional palliative care performance
status tools have good prognostic value within the
last weeks to months of life, the prognostic value
diminishes with higher performance statuses. When
these tools are applied to the older adult population,
key aspects of the geriatric assessment may be
missed [23]. In the older patient, the patient’s cur-
rent performance status must be also considered in
the context of other determinants. An individual’s
performance status may be impacted by many other
factors including nutrition, complications of thera-
pies, medication interactions, reversible medical ill-
nesses and comorbidities and these are more likely
to be present and pronounced in the older adult.
Additionally, geriatric syndromes and in particular,
frailty and falls, can significantly impact perfor-
mance status in this population. Commonly used
performance status scales in palliative care can miss
subtle impairments in instrumental activities of
daily living that is a known predictor of falls in this
&
population [25 ]. In the setting of frailty, an indi-
vidual can remain at a low-performance status for a
significant period but not have the prognosis that
their performance status would typically portend in
a younger patient with cancer. As such, if the above
circumstances are not detected, a prognosis may be
&
inaccurately drawn [23,24,25 ].
The Clinical Frailty Score (CFS – see Appendix 4,
http://links.lww.com/COSPC/A28) is a measure of
frailty that incorporates burden of disease and
dependence on others for basic and instrumental
activities of daily living. It has seven categories
ranging from 1 (very fit) to 7 (severely frail) and is
a short ’snapshot’ assessment based on clinical judg-
ment. Each one-category increment of the scale
increases the risk of death (within 6 years) and
of entry to an institution by 20%. Because of its
ease of use and predictive utility, it is commonly
used in geriatric practice [22].
With the emerging importance of the domain of
geriatric palliative care, Canadian experts from both
fields have examined the PPS and CFS to correlate
scores between the two scales in order to create a
common language and to improve communication
between geriatric and palliative care teams. This
conversion is presented Appendix 5, http://link-
s.lww.com/COSPC/A29 [26]. Clinicians providing
palliative care for the older adult with cancer would
benefit from referring to the above tool to more
www.supportiveandpalliativecare.com 25
Geriatric oncology
comprehensively assess key domains of perfor-
mance status within this population and its rela-
tionship to prognostication.
Advance Care Planning
Advance Care Planning (ACP) is a communicative
process by which an individual discusses with their
substitute decision maker (SDM) their values and
wishes in the context of healthcare delivery. It is a
dynamic and iterative process and components
include ensuring the patient and SDM’s illness
understanding, eliciting the patient’s values, goals,
fears, priorities, and end-of-life care wishes. The
importance of proper ACP in enabling healthcare
providers to provide appropriate patient-centered
care has been well established and ACP is a key
component of palliative medicine [27]. A review
of the current literature reveals that although the
value of ACP discussions is well recognized among
the older cancer patient population, uptake remains
low. There exist unique challenges in this popula-
tion to engaging in meaningful communication and
ACP discussion that involve biopsychosocial and
cultural factors [28–30].
The literature reveals that within family units,
there is a tendency to avoid discussing overall prog-
nosis with older adults and partial or nondisclosure
continues to be prevalent amongst certain cultures
[31]. Provider-related barriers in initiating ACP dis-
cussions include high prognostic uncertainty and
the lack of comfort in engaging in ACP conversa-
tions within this group and in particular, amongst
patients with cognitive impairment. A particular
challenge in ACP in the older adult is when the
patient also presents with cognitive decline. There-
fore, oncologic disease progression accompanied by
cognitive decline may compromise autonomous
decision making. The American Geriatrics Society
endorses a number of possible interventions and
recommendations to encourage early iterative
ACP for the older adult with cognitive impairment
including anticipatory guidance, use of structured
card games, and a recommendation for formal
healthcare provider training in ACP and goals of
care communication [32]. Li et al. recently presented
on the use of geriatric assessments in improving
completion of advanced directives in the older adult
with cancer [33]. There currently remains, however,
no validated clinical guidelines on engaging in ACP
conversations with individuals with cognitive
impairment. Pier et al. conducted a review of the
literature and published 32 recommendations for
engaging in ACP with patients with dementia by
combining evidence with expert opinion. These
recommendations span across eight domains of
26 www.supportiveandpalliativecare.com
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
geriatric care and include: early and routine initia-
tion of ACP, ongoing evaluation of mental capacity,
holding ACP conversations, being cognizant of the
role and importance of the patient’s caregivers, ACP
with people who find it difficult or impossible to
communicate verbally, documentation of wishes
and preferences, including information transfer,
end-of-life decision-making, and preconditions for
optimal implementation of ACP [34].
The clinician providing palliative care must be
cognizant of the above-mentioned barriers while
engaging in early and iterative ACP conversations.
Although the benefits of ACP in the older adult with
cancer is well established [28–30], there remains a
paucity of literature in guiding the clinician on how
to engage effectively in ACP conversations to com-
prehensively address the unique needs of this pop-
ulation and additional literature in this area
is needed.
End-of-life care
Trajectories of dying were first described by
researchers in an effort to map an expected, though
not guaranteed, course of decline leading to death
amongst various illnesses [35]. Results of the
research revealed different trajectories were ascribed
to differing underlying illnesses. The typical decline
in a patient with an underlying cancer was labeled
the ’Terminal Disease Trajectory’, which described a
period of functional stability followed by a progres-
sive decline in function prior to death [36]. Non-
cancer diagnoses have less predictable trajectories,
making accurate prognostication and definitive
identification of the end-of-life period more diffi-
cult. This difficulty is further underscored in the
older adult population, where the progressive
decline may be difficult to differentiate from regular
progression of chronic disease, particularly for the
frail older adult who experience a lengthy period of a
significantly low-performance status. This unclear
progression creates confusion and barriers in oppor-
tunities for the patient, family, and healthcare team
to discuss and plan for end-of-life care preferences,
specifically place of care.
Setting of care at the end-of-life for the older
adult with cancer is of particular importance. Older
adults with a prolonged frailty syndrome may reside
in a long-term care home where the culture and
resources to provide palliative and end-of-life care
varies depending on the location. In Canada, there
currently does not exist a standardized approach to
end-of-life care for older patients from long-term
care homes, with only certain homes being serviced
by home visiting palliative care specialists. For older
patients who reside in their own homes or with
Volume 15  Number 1  March 2021
 End-of-life care for the older adult with cancer Huynh and Moore
family, the decision for end-of-life care to occur in a
hospice is a complex one, which must take into
consideration the patient’s previously expressed
wishes, likelihood of caregiver burnout, as well as
the wellbeing of the remaining partner who may
themselves be an older adult. There currently exists
no guiding framework for end-of-life care for the
older adult with cancer and this underlines the
importance of early and ongoing ACP in this popu-
lation.
Families play an important role in the well-being
of those who are dying. Assuming the caregiver role
for an older dying patient may lead to physical,
emotional, spiritual, and financial distress. Family
members may experience complex emotions of
guilt, anger and powerlessness when they cannot
address the patient’s suffering. Family conflicts may
resurface between a patient and their caregiver as
well as with other involved family members. All of
these complex dynamics and emotions may impede
effective decision-making and care at the end of life.
The bereavement period for families of older
adults after death deserves special consideration.
Often times the bereavement needs of families in
these circumstances are overlooked. The death of an
older person, especially in an older patient with a
cancer diagnosis, is often perceived as an ’expected
death’ and may not be recognized and attended to in
the same way as the deaths of younger patients.
Families may feel that their loss is less relevant
and therefore not process the loss, leading to more
complicated grief. Families need to be supported
and both palliative care and oncology teams should
recognize when family members require more for-
mal bereavement support.
CONCLUSION
The importance of early comprehensive palliative
care for all patients is well established in oncology.
The current review reveals a paucity of literature in
guiding the clinician to provide comprehensive pal-
liative and end-of-life care for the older adult with
cancer. In this population, the provision of compre-
hensive palliative care must include good integra-
tion between the primary treating teams: oncology,
palliative care, and geriatrics. The importance of
integrating palliative care and oncology has been
well established and is well on its way [37]. With the
emerging field of geriatric oncology, there is also an
expanding literature integrating principles of prac-
tice between geriatric medicine and oncology. The
integration between palliative care and geriatric
medicine, however, remains in its infancy. This
paper describes key aspects of palliative and geriatric
care that ought to be considered and integrated to
1751-4258 Copyright ß 2021 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
comprehensively care for the older adult with can-
cer near the end of life. The need for an intersection
between Geriatrics and Palliative care was estab-
lished since 2005 by the American Geriatrics Society
[38] and to date, clinical collaborative efforts involv-
ing teams consisting of both palliative care and
geriatric experts have been shown to improve
patient outcomes including improved symptoms
management, decreased use of restraints, and
improved adherence to advanced directives [39].
The palliative care and the geriatric literature
remain, however, largely silo-ed with little evidence
of cross-collaboration in assessment. This review
serves to summarize key domains of palliative
and geriatric medicine to be considered while pro-
viding palliative and end-of-life care for the older
adult with cancer and underlines the ongoing dire
need for increased collaborative research in this
field.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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