Principal Investigator
PI Home Department
Source of Support
Total Cost
Anthony Jerant, M.D.
Family and Community Medicine
Robert Wood Johnson Foundation
7/2000 - 6/2004

Troubling deficits exist in the palliative care (PC) of older adults under the prevailing hospice-oriented model. We previously described a PC model - TLC - that provides a blueprint for remedying these shortfalls. In this model, PC is envisioned as Timely and team-oriented, Longitudinal, and Collaborative (including loved ones) and comprehensive. The Palliative Care in Assisted Living (PCAL) pilot study compared two TLC model-based, facility delivered interventions for improving the PC of elderly assisted living residents, a growing and under-researched population. The less intensive intervention involved one assessment followed by a PC improvement recommendation letter to the resident, family member, primary provider, and facility staff, while the more intensive intervention involved assessments and letters every three months. Primary outcomes were SF-36 Physical (PCS) and Mental (MCS) Component scores and recommendation adherence. Eighty-one subjects (mean age 85) enrolled, 58 in the more (2 facilities) and 23 in the less (1 facility) intensive group. A loved one attended 56% of baseline assessments. Most subjects expressed a preference for maintaining current quality of life over prolonging life at reduced quality. None were eligible for hospice. 418 recommendations (mean 5.1 per subject) were generated concerning symptoms, mood, functional impairments, and advance directives.

We found no significant differences in recommendation adherence between more (42%) and less (44%) intensive groups, and no significant changes in PCS and MCS scores within or between groups. However, a loved one's attendance of the baseline assessment was associated with improved PCS scores (p = 0.04). Our pilot had numerous methodological limitations that could account for the lack of significant outcome effects. In this context, and given the myriad unmet PC needs we detected, the TLC model seems a promising alternative to the hospice model. More definitive intervention studies based on the TLC model appear warranted.