Flourishing at the End of Life

Public Discourse | By Xavier Symons, John Rhee, Tyler VanderWeele

Dying is part of life, but most people dread their final days. The end of life, which often takes the form of protracted terminal illness, can involve significant pain and suffering as well as functional limits in day-to-day living. Is it still possible for human beings to flourish at the end of life?

While dying may be a time when agency and quality of life are limited, the end of life also presents unique possibilities for the realization of human goods. Some dying patients discover meaning by reflecting on the events of their lives and come to a deeper appreciation of their own life legacy. Terminal illness also presents opportunities for a deepening of close social relationships and the fulfillment of relationship commitments. Paradoxically, the end of life can be a catalyst for gratitude and self-transcendence. It is worth asking, then: can we flourish even as we approach death? And how can we help our loved ones flourish in their final days? 

Human Flourishing and End-of-Life Care

Humans have long grappled with the question of what it means to flourish. According to Aristotle, flourishing is best understood as the action of a living thing in accord with its proper function. The English word flourishing has as its point of reference the vigorous development of a living thing over time. In the case of human beings, Aristotle takes this vigorous development to be constituted by rational activity in accord with virtue, given that a human being can be defined as a rational animal.

One challenge to the notion of flourishing at the end of life is that the human body is, by definition, past its developmental prime and in a phase of active and sometimes rapid decline. One could question, then, whether flourishing is an appropriate concept to discuss in the context of end-of-life care. Today, people most commonly die from longer and more protracted forms of illness like heart disease, cancer, or neurodegenerative disease. These conditions can involve considerable pain and suffering and loss of function that preclude participation in social life and/or meaningful personal activities. Sometimes these conditions will be accompanied by dementia symptoms, which compound a sense of lost dignity among the sick and their loved ones.

The development of the field of palliative care and advances in pain science in recent decades have meant we can provide more humane care for the dying. Clinicians and researchers have also developed creative approaches to restoring a sense of meaning and hope to the lives of people suffering from terminal illnesses. For example, through dignity therapy in palliative care, healthcare professionals conduct informal interviews with patients, to explore sources of personal meaning and purpose and to clarify how those sources of value outlast one’s own life. This legacy work can significantly improve patient and family outcomes in the dying process and can ameliorate death-related anxiety and depression.

But end-of-life care is, in many cases, primarily focused on symptom control and pain relief. Flourishing may be perceived as out of reach for dying patients; attention is, instead, given to achieving comfort and psychological equilibrium in one’s final days and hours.

End-of-Life Flourishing

But certain human goods are uniquely realizable in end-of-life contexts, and dying may, paradoxically, allow us to enter more deeply into our own humanity. This fact deserves more attention than it has received to date. We would focus on three areas in particular: narrative consolidation, deepening relationships, and the cultivation of virtue.

Human beings can undergo a strengthening of meaning at the end of life through reflection on life experience. Several philosophers have argued that human beings are natural storytellers. Every community has its own stories with which members come to form a sense of shared identity…

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Policymakers Should Help Address the Crisis of Older Adult Falls

Forbes | By Richard Howells

Older adult falls result in 38,000 deaths, 1 million hospitalizations, and 3 million emergency department visits each year, along with $80 billion in health care costs, including $53 billion to Medicare.
 
Too many Americans have lost loved ones due to falls. The Centers for Disease Control and Prevention (CDC) estimates that falls among older adults result in 38,000 deaths, 1 million hospitalizations, and 3 million emergency department visits each year, along with $80 billion in health care costs, including $53 billion to Medicare. Yet, most falls are preventable, and most occur at home. We can—and must—do more to help older adults avoid fatalities and injuries like fractures and traumatic brain injury from falls.
 
Given the enormous health and economic toll, one might think policymakers would make this issue a priority. Unfortunately, this hasn’t been the case. Despite the occasional Congressional champion, introduction of legislation, or agency activity on falls prevention, the attention given to this issue does not match its urgency. For example, falls prevention has not been a significant focus this year in Congress’ appropriations process or in the committees tasked with improving health or reducing health care costs.
 
Falls usually occur due to one or a combination of three reasons: home hazards, such as a lack of bathroom grab bars, loose rugs, stairs, poor lighting, or out-of-reach electrical outlets; medication side effects or medical conditions, such as visual or cognitive impairment; and, a lack of balance caused by a variety of illnesses, disabilities, or physical inactivity.
 
In previous testimony to the U.S. Senate Special Committee on Aging, I called for the executive branch to develop a falls prevention action plan and to better coordinate home modification programs to substantially reduce falls and their associated health care costs. Here are three specific steps that should be taken:
 
First, policymakers should make more community-based falls prevention programs accessible to seniors. This includes creating pathways for Medicare beneficiaries with traditional fee-for-service to access these programs, as well as providing incentives for Medicare Advantage plans. Programs such as A Matter of Balance, the Otago Exercise Program, and tai chi exercise programs have been recommended by the U.S. Preventive Services Task Force to prevent falls in community-dwelling adults 65 years or older who are at increased risk.
 
Second, policymakers should pay clinicians specifically to screen for falls risk, intervene to reduce risk factors, and refer patients to additional falls prevention programs and specialists. The CDC’s Stopping Elderly Accidents, Deaths & Injuries (STEADI) tool offers clinicians an evidence-based algorithm to help patients reduce fall risk. Currently, Medicare pays clinicians to assess for falls risk as part of the Annual Wellness Visit. 
 
However, falls prevention is just one of several dozen components of the visit, and there often is not enough time to focus on it. Moreover, only a minority of seniors receive the wellness visit.
 
Third, government agencies should identify and streamline the various home modification resources available across federal agencies to help older adults make their homes more age-friendly. This should include facilitating opportunities for our most vulnerable seniors enrolled in both Medicare and Medicaid. The aging and disability networks, such as Area Agencies on Aging and Aging and Disability Resource Centers, reach millions of older adults and could be effectively utilized to disseminate these resources.