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Part VI: Reorienting Health Services
- Public Health and Healthy Aging (Chapter 24 and Personal Reflection 5)
- Older Adults: Community Health and Social Services (Chapter 25)
- Regaining, Maintaining, and Improving Independence in Daily Life (Chapter 26)
- Nursing Homes / Long-Term Care (Chapter 27)
- Reorienting Mental Health Services for Older Adults (Chapter 28)
- Older Adults, Caregivers, and Caregiving (Chapter 29)
- Substance Use and Older Adults (Chapter 30)
- Death and Dying (Chapter 31 and Personal Reflection 6)
Public Health and Healthy Aging
(Chapter 24 by Pegeen Walsh and Personal Reflection 5 by Connie Swinton)
CanAge. (2021). Adult Vaccination in Canada Cross-Country Report Card. https://www.canage.ca/what-s-new
This report card assesses for the first time how each province and territory in Canada is performing against the standards set by the National Advisory Committee on Immunization related to core vaccine preventable diseases (e.g., influenza, pneumonia, shingles, tetanus, diphtheria and Pertussis). The report reveals that governments are failing seniors on issues of funding, access and awareness of vaccines putting seniors at risk of severe health outcomes, hospitalization and death; next steps that each jurisdiction should take for strengthening their efforts are also outlined.
De Biasi, A., Wolfe, M., Carmody, J., et al. (2020). Creating an age-friendly public health system. Innovation in Aging, 4(1). https://doi.org/10.1093/geroni/igz044
This article describes how the Florida Departments of Health and Elder Affairs piloted a framework that saw their agency take a more proactive approach to improving the health and well-being of the older adult population. The authors argue that by creating an age-friendly public health system, translating evidence into public health practice and investing more in prevention, public health agencies can have a greater impact on healthy aging.
Donnellan, K., Sands, T., Bayer, E., et al. (2021). Creating a culture of healthy aging in public health. Journal of Public Health Management and Practice, 27(2): 213–214. https://doi.org/10.1097/phh.0000000000001339
This article outlines ways that public health agencies can promote a culture of health aging and bring a specific focus on older adults throughout the practice of public health. This can range from advocating for healthy aging, influencing other agencies (e.g., social services, city planning) to integrate health aging into their plans and policies to the inclusion of aging in public health communications.
Jeffery, B., Muhajarine, N., Johnson, S., et al. (2018). An Overview of Healthy Aging Strategies in Rural and Urban Canada. Saskatchewan Population Health and Evaluation Research Unit, University of Regina and University of Saskatchewan. https://spheru.ca/publications/files/Healthy%20Aging%20Enviro%20Scan%20Report%20June%202018%20FINAL%2026-Sep-2018.pdf
This document includes an environmental scan outlining healthy aging frameworks and interventions across Canada at the federal and provincial/territorial levels of government to support planning for older adults in rural communities and beyond. The findings point to gaps in strategies, healthy aging frameworks and interventions and some key areas where action could be taken to improve healthy aging in place.
National Prevention Council. (2016). Healthy Aging in Action. Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General. https://www.hhs.gov/sites/default/files/healthy-aging-in-action-final.pdf
This report provides recommendations to public health officials and others to introduce multi-sector prevention and wellness initiatives that can promote healthy aging (e.g., through injury prevention, managing chronic conditions, social engagement, eliminating health disparities).
Skarstedt, C. (2019, January 18). 95-year-old Peterborough woman pens memoir on her 45 years in nursing. Peterborough Examiner. https://www.thepeterboroughexaminer.com/entertainment/books/2019/01/18/95-year-old-peterborough-woman-pens-memoir-on-her-45-years-in-nursing.html
A short write-up and photo of Connie Swinton (age 95) on the occasion of her book launch of From Tofield to the top of the world: 45 years of public health nursing in Canada and abroad 1945–1990.
Swinton, C. A. (2019). From Tofield to the top of the world: 45 years of public health nursing in Canada and abroad 1945–1990. https://www.amazon.ca/Tofield-Top-World-public-nursing/dp/1791381464
Connie’s career in public health nursing spans more than four decades and circumnavigates the globe. She has worked with the Victorian Order of Nurses, taught at the University of Toronto, been a consultant to Health Canada, and, with CIDA and other organizations, shared her public health expertise and leadership in countries around the world. She has served in rural Alberta, in the mountain regions of Nepal, in the deserts of Sudan, in Vietnam in the 1970s during the war, in Pakistan during the assassination of a president, and on less dramatic projects in Indonesia and Thailand. Her story is in many ways a history of the delivery of health services here in Canada and of Canada’s international role in raising standards of health care in the developing world.
Relevant Websites and Organizations
Note: Please see the organizations and websites in the General Resources section. Many of them are involved in public health and aging. Additional ones here are specific to public health and healthy aging.
Dental Hygiene Canada
This website provides information on seniors’ oral health, preventive oral health care, dental coverage, oral health and long-term care, and substance use and oral health as well as further readings for older adults and their caregivers.
Frontiers in Public Health: Aging and Public Health
The Frontiers in Public Health website section on aging and public health provides open access to knowledge about the needs of an aging population and most effective strategies to promote health for older adults.
National Institute on Aging
This site features information for the US Department of Health and Human Services National Institute on Healthy Aging.
Public Health Agency of Canada: Public Health Infobase
This website offers a selection of tools for accessing and viewing public health data. By using various search options on key topics or by selecting criteria through drop-down menus, the Infobase enables users to view data from different data sources in various formats. The users can interact with data visualisations or view infographics and charts to gain insight on chronic diseases, mental health, risk and protective factors, and associated determinants of health.
Trust for America’s Health
The Trust for America’s Health website has information on their partnership with US state and local health departments to implement a public health framework to improve the health and well-being of older adults. The site includes case studies and best practices, tools and training resources.
Vaccine4Lif is the website for the World Coalition on Adult Vaccination and a program aimed to mobilize knowledge on the importance of a life course approach to vaccination, and equitable access to adult vaccinations developed and led by the International Federation on Ageing.
actionalz. (2020, Aug. 10). Curriculum Module 3D: Public Health Impact: Risk Reduction and Primary Prevention. (8 minutes). https://www.youtube.com/watch?v=IaeafSYcLz4
This video focuses on how risk reduction and primary prevention can impact Alzheimer’s and other dementias.
helpage. (2017, Jul. 13). What is the life course approach to ageing? (3 minutes). https://www.youtube.com/watch?v=qMLqgK1jfR0
Describes the life course approach to public health and healthy aging.
International Federation on Ageing: Fostering Healthy Aging. https://ifa.ngo/news-and-resources/videos/fostering-healthy-ageing/
Includes two videos on adult immunization: Dr. Jane Barratt, Life Course Approach to Immunization (41 seconds) and Not Just for Kids: Supporting Healthy Ageing Through Vaccination in High-Risk Populations (7 minutes).
The Longevity Forum. (2020, Jan. 19). Linda Fried, Dean, Mailman School of Public Health, “Realising the Opportunities of Longer Lives.” (5 minutes). https://www.youtube.com/watch?v=QNInmlHXmC0
In this video, the Dean of Columbia University School of Public Health, Linda Fried talks about “Realising the Opportunities of Longer Lives” to improve the well-being of older adults.
PAHO TV. (2016, Oct. 18). What is the life course approach to public health? (5 minutes). https://www.youtube.com/watch?v=3OBFYIXmAwQ
Describes the life course approach to public health and healthy aging.
Seniors Health Knowledge Network. (2015, Dec 14). How a Public Health Lens Can Contribute to the Field of Health and Aging. (56 minutes). https://www.youtube.com/watch?v=lardWapDxNw
This webinar, by two Master of Public Health candidates, describes how public health professionals can contribute to the field of aging. It features two case studies on falls prevention and Age-Friendly Communities from intersectoral projects done within the Centre for Studies in Aging and Health at Providence Care in Kingston, Ontario to improve health outcomes for older adults.
Older Adults: Community Health and Social Services
(Chapter 25 by Laura Kadowaki, Kahir Lalji, and Marcy Cohen)
Cohen, M., & Spinder, C. (2017). Raising the Profile Project: Findings and Recommendations from the Community Consultations. Raising the Profile Project. http://www.seniorsraisingtheprofile.ca/wp-content/uploads/2017/08/RPP-Findings-and-Recommendations-from-the-Community-Consultations.pdf
This report summarizes the key findings from the seven regional consultations that were held in 2017 as a part of the Raising the Profile Project.
Kadowaki, L., & Cohen, M. (2017). Raising the Profile of the Community-Based Seniors’ Services Sector in B.C.: A Review of the Literature. Raising the Profile Project. http://www.seniorsraisingtheprofile.ca/wp-content/uploads/2017/06/RPP-Literature-Review.pdf
This report provides evidence showing that a greater emphasis on health promotion and prevention programming and interventions that foster resilience can result in significant improvements in seniors’ health, and reductions in the use of (and costs to) the healthcare system. In particular, it highlights nutrition, physical activity, and social support as three key areas in which community-based seniors’ services may substantially impact the health and well-being of seniors and reduce the use and cost of healthcare services.
Lalji, K. (2021, April). Categorically Speaking. https://www.uwlm.ca/wp-content/uploads/2021/05/Categorically-Speaking_Healthy-Aging-OP-ED_04-22-22.pdf
In this op-ed, Kahir Lalji, BC Provincial Director of United Way Healthy Aging, argues that categorical thinking about older persons is harmful from a social perspective – and a human one. When we group people together in our thinking, based on just a few attributes (or worse, stereotypes), they become one-dimensional, and our appreciation and empathy are greatly diminished.
United Way of the Lower Mainland. (2017). United Way of the Lower Mainland: 2017/18 Healthy Aging Report. https://healthyagingcore.ca/sites/default/files/2018-09/ha_annual_report_2017_18_hires.pdf
This annual report from the United Way of the Lower Mainland provides details on their Healthy Aging Strategy and various initiatives associated with it.
Relevant Websites and Organizations
Healthy Aging CORE
Healthy Aging CORE is the online virtual network and provincial knowledge hub that has been developed for the CBSS sector in BC.
Project Impact Healthy Aging
Project Impact Healthy Aging, the CBSS developmental evaluation course described in this chapter, has published a book of evaluation case studies from its first cohort of students.
Raising the Profile Project
The Raising the Profile Project website contains an overview of the project as well as key documents and resources from the project. You can access documents from the Raising the Profile Project, including the literature review, program profiles, and other resources from the project at this site. Below, you can find a selection of Canadian reports providing facts and statistics on the key CBSS impact areas (physical activity, nutrition, and social support) discussed in the Raising the Profile Project literature review
Revelstoke Community Response Network, Healthy Aging CORE. (2020). Take Time for Seniors. (3 minutes). https://bc.healthyagingcore.ca/resources/video-take-time-seniors-re-ageism
This video features two young people on their bikes reflecting on their views of seniors and their knowledge about the mistreatment of older people, through the question “What do you think about seniors?”
Regaining, Maintaining, and Improving Independence in Daily Life
(Chapter 26 by Nicole Dubuc and Bryony Beresford)
Ageing, Disability and Home Care Department of Human Services NSW. (2010). Toward an Enabling Approach in Community Care: Empowering People, Enhancing Independence, Enriching Lives. https://webarchive.nla.gov.au/awa/20111012011611/http://pandora.nla.gov.au/pan/129902/20111012-1214/www.adhc.nsw.gov.au/__data/assets/file/0010/233965/Better_Practice_Project_-_Discussion.pdf
This document describes enabling approach in Home and Community Care in NSW, Australia, for frail older people and people with a disability living in their community. It highlights how people can benefit from enabling approach, encourage discussion and suggest some next steps for people and organisations interested in this approach.
Francis, J., Fisher, M., & Rutter, D. (2011). SCIE Research Briefing 36: Reablement: A Cost-Effectiveness Route to Better Outcomes. Social Care Institute for Excellence. https://www.scie.org.uk/publications/briefings/briefing36/
This is one in a series of research briefings about preventive care and support for adults.
Hjelle, K. M., Tunland, H., Forland, O., Alvsvag,Nope H. (2016). Driving forces for home-based reablement: A qualitative study of older adults’ experiences. Health and Social Care in the Community 25(5): 1581–1589. https://doi.org/10.1111/hsc.12324.
This article explain how reablement is applied in Norway and explore older peoples’ experiences of participating in reablement. It covers topics such as how older adults experience the co-operation with staff, being in charge of their own goals, and how they are or become motivated.
National Institute for Health and Care Excellence (NICE). (2017). Intermediate Care Including Reablement. NICE Guideline 74. https://www.nice.org.uk/guidance/ng74
This guideline covers referral and assessment for intermediate care and how to deliver the service. Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care.
Parker, G. & the More team. (2014). Intermediate Care, Reablement or Something Else? A Research Note about the Challenges of Defining Services. Social Policy Research Unit. University of York, UK. https://www.york.ac.uk/media/spru/ICR.pdf
This working paper from members of the MORE team in York, UK, explore the policy and practice background to the development of reablement and intermediate care in order to help explain some of definitional confusion. Then, they propose a classification of the operational or functional objectives of the two types of care that may assist when trying to evaluate one or the other or both.
Poulos, C. & Poulos, R. (2019). A function-focused approach in primary care for older people with functional decline: Making the most of reablement and restorative care. Australian Journal of General Practice, 48(7): 434–439. https://doi.org/10.31128/ajgp-01-19-4808.
This paper help to understand vocabularies related to “Reablement” “Restorative care” “Rehabilitation” and “Function-focused approach” in primary care.
Poulos, C., Bayer, A., Beaupré, L., et al. (2017). A comprehensive approach to reablement in dementia. Alzheimer’s & Dementia, 3(3): 450–458. https://doi.org/10.1016/j.trci.2017.06.005.
This article presents a comprehensive reablement approach across seven domains for the person living with mild-to-moderate dementia.
Silke, F., Rostgaard, T., Parsons, M., & Burton, E. Development of an internationally accepted definition of reablement: A Delphi study. Ageing and Society: 1–16. https://doi.org/10.1017/S0144686X20000999.
This article provides conceptual clarity about reablement. A study consisting of four Web-based survey rounds with 82 reablement experts from 11 countries permitted to reach an agreement on five characteristics (e.g. person-centred), seven components (e.g., goal-oriented treatment plan) and five aims (e.g. increase clients’ independency) about the concept of reablement.
Social Care Institute for Excellence (SCIE). (2020). Role and Principles of Reablement. https://www.scie.org.uk/reablement/what-is/principles-of-reablement
This briefing is an overview of the role and principles of reablement in the social care sector. It is designed for those working in reablement or commissioning it, but may also be useful to carers and people receiving reablement.
Social Care Institute for Excellence (SCIE). (2013). Maximising the Potential of Reablement. SCIE Guide 49. https://www.scie.org.uk/publications/guides/guide49/
This guide provides recommendations for maximising the potential of reablement in improving people’s outcomes and delivering a cost-effective service across health and social care.
Relevant Websites and Organizations
Ottawa Hospital Research Institute: Patient Decision Aids
Patient decision aids are empowering tools that help people become involved in decision-making by making explicit the decision that needs to be made, providing information about the options and outcomes, and clarifying personal values. They are designed to complement, rather than replace, counselling from a health practitioner and social and home care. This comprehensive site is the result of years of worldwide research and collaboration pioneered by Annette M. O’Connor, Emeritus Professor at the University of Ottawa and the first nursing professor to be inducted into the Canadian Medical Hall of Fame.
Social Care Institute for Excellence
This agency is independent and people-focused, operating at policy and practice levels with a huge database of 'what works' good practice, eLearning tools and resources. Working beyond and across social care and health and children's and adult’s sectors, they contribute to the development and implementation of better care, support and safeguarding at national and local level in United Kingdom.
Social Care Institute for Excellence (SCIE). (2016). Prevention: Reablement. (10 minutes). https://www.scie.org.uk/reablement/videos/prevention
This film briefly shows the empowerment approach as applied in England. It provides an introduction to home care reablement.
Nursing Homes / Long-Term Care
(Chapter 27 by Pat Armstrong, Hugh Armstrong, and Jacqueline Choiniere)
Armstrong P., Armstrong, H., & Choiniere, J. (2015). Before It’s Too Late: A National Plan for Safe Seniors’ Care. Canadian Federation of Nurses Unions. https://nursesunions.ca/wp-content/uploads/2017/05/CFNU-Seniors-Book-2015_FINAL.pdf
Five years before the pandemic, the Canadian Federation of Nurses Unions named the problems in long-term care (LTC) and called for a national plan for safe, integrated seniors care that respects older persons, staff, and the importance of relationship care. This report written by Pat Armstrong and colleagues made all the right evidence-based recommendations, which were unfortunately mostly ignored by governments and owners of LTC residences.
Armstrong, P., Armstrong, H., Choiniere, J., Struthers, J., & Lowndes, R. (2020). Re-imagining Long-Term Residential Care in the COVID-19 Crisis. Ottawa: Canadian Centre for Policy Alternatives. https://www.policyalternatives.ca/publications/reports/re-imagining-long-term-residential-care-covid-19-crisis
Based on a 10-year study that used multiple methods including ethnography, this policy paper identifies promising practices for moving forward in an area where health is not being promoted.
Armstrong, P., Armstrong, H., Buchanan, D., et al. Investing in Care, Not Profit: Recommendations to transform long-term care in Ontario. Canadian Centre for Policy Alternatives. https://www.policyalternatives.ca/publications/reports/investing-care-not-profit
This report provides the facts about for-profit LTC facilities and the catastrophe in care during the pandemic. It concludes: “We have both the need and opportunity to chart a new course for LTC. It is essential to any reform agenda that Ontario transition from policies designed to attract and support private equity investment in long-term care. That model has failed the people of Ontario, and caused great harm to the residents of LTC homes and their families.”
Canadian Centre for Policy Alternatives. Booklets on LTC. https://www.policyalternatives.ca
Four booklets are available for free download, including:
- Armstrong, P. & Braedley, S. (eds.) (2016). Physical Environments for Long-Term Care: Ideas Worth Sharing.
- Armstrong, P. & Daly, T. (eds.) (2017). Exercising Choice in Long-Term Residential Care.
- Armstrong, P. & Lowndes, R. (eds.) (2018). Negotiating Tensions in Long-Term Residential Care: Ideas Worth Sharing.
- Baines, D. & Armstrong, P. (eds.) (2015–2016). Promising Practices in Long Term Care: Ideas Worth Sharing.
Estabrooks, C., Straus, S., Flood, C., et al. (2020). Restoring Trust: COVID-19 and the Future of Long-Term Care in Canada. Ottawa: Royal Society of Canada. https://rsc-src.ca/en/restoring-trust-covid-19-and-future-long-term-care
This policy paper, written by a group of experts on long-term care brought together during the pandemic by the Royal Society of Canada, draws together an extensive range of material on policy and practices to set out an agenda for transforming long-term care.
Flood, C., MacDonnell, V., Philpott, J., et al. eds. (2020). Vulnerable: The Policy, Law and Ethics of COVID-19. Ottawa: University of Ottawa Press.
A multi-disciplinary, rapidly produced book intended to influence strategies for change, it exposes vulnerabilities in institutions, governance and law at the international and national levels.
Liu, M., Maxwell, C., Armstrong, P., et al. (2020). COVID-19 in long-term care homes in Ontario and British Columbia. Canadian Medical Association Journal, 192(47): E1540–E1546. https://doi.org/10.1503/cmaj.201860
The governments in Ontario and British Columbia introduced different strategies at different times with quite different results for long-term care, as this article demonstrates.
Ontario’s Long-Term Care COVID-19 Commission Report. (2021, May 20). Final report. http://www.ltccommission-commissionsld.ca
The Ontario Long-Term Care COVID-19 Commission released a final report fulfilling their mandate to examine the pandemic response for long-term care in Ontario. The report includes the state of long-term care before COVID-19, the deficiencies in Ontario’s pandemic preparedness, the COVID-19 crisis in long-term care and its devastating impacts, the actions and inactions that contributed to the devastation in long-term care during the COVID-19 pandemic, best practices and promising ideas that can be adopted and expanded to improve long-term care, and final recommendations for change. The report provides the foundation for a critically needed discussion and immediate action to effectively transform long-term care in Ontario and other provinces. The recommendations have merit for application across Canada.
Picard, A. (2021). Neglected no more: The urgent need to improve the lives of Canada's elders in the wake of a pandemic. Penguin Random House Canada.
In this book, journalist André Picard takes a hard look at how we came to embrace mass institutionalization and lays out what can and must be done to improve the state of care for older people. Picard shows that the entire care system for older people—fragmented, underfunded, and unsupported—is long overdue for a fundamental rethink. We need to find ways to ensure seniors can age gracefully in the community for longer, with supportive home care and respite for family caregivers, and ensure that long-term care homes are not warehouses of isolation and neglect.
Welsh, M. (2021, May 1). A watershed moment: Amid the despair over the state of LTC in the province, there is hope things will get better. Toronto Star. https://www.thestar.com/news/gta/2021/05/01/a-watershed-moment-amid-the-despair-over-the-state-of-ltc-in-the-province-there-is-hope-things-will-get-better.html
In this article, staff reporter Moira Walsh writes about the hope contained in Ontario’s Long-Term Care COVID-19 Commission Report including the value of person-centred care as the way to transform a nursing home system ignored for decades by politicians, bureaucrats, and the public, and a philosophy of care that is anchored in respect, compassion, and kindness for the people who live and work in long-term care. Without a legislated and funded embrace of progressive models of care, as the Commission recommended, Ontario nursing home residents, including the future seniors, will live in facilities, not homes.
Relevant Websites and Organizations
Canadian Health Coalition
The Canadian Health Coalition (CHC) is a public advocacy organization dedicated to the preservation and improvement of public health care in Canada. The site has multiple resources on long-term care and complimentary services
Re-imagining Long-Term Residential Living
This website contains information on Re-imagining Long-term Residential Care: An international study of promising practices and related projects, publications, events, and newsletters.
Ontario Health Coalition
Their primary goal is to protect and improve public health care system in Ontario. They work to honour and strengthen the principles of the Canada Health Act. The site has multiple resources on long-term care and complimentary services
TVO. (2021, Mar. 3). Has Ontario Failed Long-Term Care? The Agenda with Steve Paikin. (30 minutes). https://www.youtube.com/watch?v=cYWzAcOP29w
Residents and staff in the LTC sector were devastatingly affected during the COVID-19 emergency. A panel of experts discuss how and why we got here: Peter Shawn Taylor, senior features editor at C2C Journal; Vivian Stamatopoulos, long-term care researcher with Ontario Tech University and co-founder of the advocacy group Doctors for Justice in LTC; Donna Duncan, CEO of the Ontario Long Term Care Association; and Pat Armstrong, distinguished research professor of sociology at York University.
Reorienting Mental Health Services for Older Adults
(Chapter 28 by Kimberley Wilson)
Farid, D., Li, P., Da Costa, D., et al. (2020). Undiagnosed depression, persistent depressive symptoms and seeking mental health care: Analysis of immigrant and non-immigrant participants of the Canadian Longitudinal Study of Aging. Epidemiology and Psychiatric Sciences, 29. https://dx.doi.org/10.1017%2FS2045796020000670
This study examined differences in prevalence and predictors of undiagnosed depression (UD) between immigrants and non-immigrants at baseline and persistent and/or emerging depressive symptoms 18 months later.
Heisel, M. J., Neufeld, E., & Flett, G. L. (2016). Reasons for living, meaning in life, and suicide ideation: Investigating the roles of key positive psychological factors in reducing suicide risk in community-residing older adults. Aging & Mental Health,* 20*(2): 195–207. https://doi.org/10.1080/13607863.2015.1078279
This article investigates the roles of reasons for living and meaning in life in potentially promoting mental health and well-being and protecting against suicide ideation among community-residing older adults.
Hwang, T. J., Rabheru, K., Peisah, C., et al. (2020). Loneliness and social isolation during the COVID-19 pandemic. International Psychogeriatrics, 32(10): 1217–1220.
This paper aims to describe the nature of loneliness and social isolation among older persons, its effect on their health, and ways to cope with loneliness and social isolation during the COVID-19 pandemic.
Kennedy, M., Helfand, B. K., Gou, R. Y., et al. (2020). Delirium in older patients with COVID-19 presenting to the emergency department. JAMA Network Open, 3(11): e2029540. https://doi.org/10.1001/jamanetworkopen.2020.29540.
In this cohort study of 817 older adults with COVID-19 presenting to US emergency departments, delirium was common and often was seen without other typical symptoms or signs.
Linkages Reading List: Delirium in Older Adults. (2019). https://sagelink.ca/wp-content/uploads/2020/01/Delirium-in-Older-Adults.pdf
Topics include strategies for different health care settings, risk factors, recovery, post-operative delirium, prevention, diagnosis and management, antipsychotic medication, delirium at the end of life, delirium and agitation, delirium in dementia, non-pharmacological interventions, comorbidity, and mortality. Last reviewed November 2019.
Linkages Reading List: Dementia in Older Adults. (2019). https://sagelink.ca/wp-content/uploads/2020/01/Dementia-in-Older-Adults.pdf
Topics include diagnosis and treatment, clinical imaging, pathology, frontotemporal dementia, Lewy body dementia, pharmacological management, mild cognitive impairment, risk factors, considerations for Indigenous peoples, hoarding, dual sensory loss, brain injury, comorbidity, agitation, pain, sleep, and suicide. Last reviewed November 2019.
Linkages Reading List: Supporting Care Partners of Those with Dementia. (2019) https://sagelink.ca/wp-content/uploads/2020/01/Supporting-Care-Partners-of-Those-with-Dementia.pdf
This reading list features resources intended to educate and support care partners of people with dementia. Last reviewed December 2019.
Linkages Reading List: Depression in Older Adults. (2019). https://sagelink.ca/wp-content/uploads/2020/01/Depression-in-Older-Adults.pdf
Topics include assessment and treatment, pharmacotherapy, non-pharmacological treatments, comorbidity, and suicidal behaviour. Last reviewed November 2019.
Linkages Reading List: Mental Health Considerations for Older Adults. (2019). https://sagelink.ca/wp-content/uploads/2020/01/Mental-Health-Considerations-for-the-Older-Adult.pdf
Topics include ageism, special considerations for LGBT elders, comorbidities, self-harm, grief, PTSD, traumatic brain injury, dementia, anxiety disorder, anorexia, personality disorder, delirium, depression, and non-pharmacological treatment options. Last reviewed December 2019.
Livingston, G., Sommerlad, A., Orgeta, V., et al. (2017). Dementia prevention, intervention, and care. The Lancet, 390(10113): 2673–2734. https://doi.org/10.1016/s0140-6736(17)31363-6.
The Lancet Commission on Dementia Prevention, Intervention, and Care met to consolidate the huge strides that have been made and the emerging knowledge as to what should be done to prevent and manage dementia.
Menec, V. H., Newall, N. E., Mackenzie, C. S., et al. (2020). Examining social isolation and loneliness in combination in relation to social support and psychological distress using Canadian Longitudinal Study of Aging (CLSA) data. PloS one, 15(3): e0230673. https://doi.org/10.1371/journal.pone.0230673.
This study examines: (1) the relationship between four groups derived from combining social isolation and loneliness (socially isolated and lonely; only socially isolated; only lonely; neither socially isolated nor lonely) and the desire for more social participation and social support; and (2) the relationship between the four groups and psychological distress.
Ries, J. (2019, May 16). Worried About Dementia? Here Are 5 Ways to Cut Your Risk. Healthline. https://www.healthline.com/health-news/here-are-5-ways-to-cut-your-dementia-risk
This articled summarizes five healthy habits the WHO recommends adopting to protect your brain and cut your dementia risk.
Seitz, D., Purandare, N., & Conn, D. (2010). Prevalence of psychiatric disorders among older adults in long-term care homes: A systematic review. International Psychogeriatrics, 22(7): 1025–1039. https://doi.org/10.1017/s1041610210000608.
This study reviews the prevalence of common psychiatric disorders in LTC populations.
Weir, E., & Seitz, D. (2017). Dementia-friendly communities: Where home care and mental health intersect. CMAJ 189(16): E581–E582. https://doi.org/10.1503/cmaj.170370.
Discussion of a national strategy for dementia-friendly communities.
World Health Organization. (2019). Risk reduction of cognitive decline and dementia: WHO guidelines. https://apps.who.int/iris/bitstream/handle/10665/312180/9789241550543-eng.pdf
These new WHO guidelines provide the knowledge base for health care providers, governments, policy-makers, and other stakeholders to reduce the risks of cognitive decline and dementia through a public health approach. As many of the risk factors for dementia are shared with those of non-communicable diseases, the key recommendations can be effectively integrated into programmes for tobacco cessation, cardiovascular disease risk reduction, and nutrition.
Yu J, Xu W, Tan C, et al. (2020). Evidence-based prevention of Alzheimer’s disease: Systematic review and meta-analysis of 243 observational prospective studies and 153 randomised controlled trials. Journal of Neurology, Neurosurgery & Psychiatry, 91, 1201–1209.
Evidence on preventing Alzheimer’s disease (AD) is challenging to interpret due to varying study designs with heterogeneous endpoints and credibility. This systematic review and meta-analysis of current evidence with prospective designs proposes 21 evidence-based suggestions on AD prevention. With credible though inconclusive evidence, the suggestions target 10 risk factors including diabetes, hyperhomocysteinaemia, poor BMI management, reduced education, hypertension in midlife, orthostatic hypotension, head trauma, less cognitive activity, stress, and depression.
Relevant Websites and Organizations
The Alzheimer Society of Canada
The mission of the Alzheimer Society of Canada is “to alleviate the personal and social consequences of Alzheimer’s and related diseases and to promote the search for causes, treatments and a cure.” Explore their website and learn about dementia, current research in the field, and what supports are available.
The brainXchange is a network of people dedicated to improving quality of life and supports for persons with or at risk of having brain-health needs related to dementia, mental health and neurological conditions related to aging or have experienced brain health changes earlier in life that are now more complex with aging.
Canadian Coalition for Seniors’ Mental Health (CCSMH)
The Canadian Coalition for Seniors’ Mental Health (CCSMH) has a mission to “promote the mental health of seniors by connecting people, ideas and resources.” They publish interdisciplinary guidelines on common mental illnesses in late life and have accompanying resources and toolkits. These include an Updated Canadian Guidelines on the Prevention, Assessment and Treatment of Depression among Older Adults (May 2021)
Dementia Dialogues are podcasts that feature people with dementia and their care/life partners. The goal is to share lived experiences of living with dementia to help raise awareness and understanding of what it means to live with dementia.
If you’d like to know more about assessment and treatment of depression, delirium, and cognitive changes, engage with the frailty e-learning modules. Frailty e-learning modules are open-access interactive geriatric learning modules based on the Geriatrics interprofessional interorganizational Collaboration (GiiC) toolkit developed by the RGPs of Ontario. Users take on a senior character and follow their journey through the health system.
Hartford Institute for Geriatric Nursing (HIGN)
The mission of the Hartford Institute for Geriatric Nursing (HIGN) is to ensure older adults achieve optimal health and quality of life. The “Try-This” series of assessment tools includes evidence-informed assessment tools and interactive videos to see assessment in action.
The Mental Health Commission of Canada (MHCC)
The Mental Health Commission of Canada (MHCC) supports projects and promotes research findings that help policy makers, providers, and the public to ensure that older adults in Canada receive the supports they need to support their mental health as they grow older.
Mental Health First Aid for Seniors
If you’re interested in applying what you have learned in this chapter you might want to consider taking Mental Health First Aid for Seniors. MHFA for Seniors is a program run through the MHCC and is intended to “increase the capacity of seniors, families (informal caregivers), friends, staff in care settings and communities to promote mental health in seniors, prevent mental illness and suicide wherever possible in seniors and intervene early when problems first emerge.”
Provincial Geriatrics Leadership Ontario (PGLO)
Provincial Geriatrics Leadership Ontario (PGLO) was previously known as the Regional Geriatrics Programs of Ontario. Although a provincial site, clinicians and learners from across Canada can access evidence-based resources related to assessment and promoting senior friendly spaces.
Older Adults, Caregivers, and Caregiving
(Chapter 29 by Laura M. Funk)
Armstrong, P. (2013). Unpaid Health Care: An Indicator of Equity. Pan American Health Organization: Office of Gender, Diversity and Human Rights. https://www.paho.org/hq/dmdocuments/2013/Unpaid-health-care-indicator-equity-Pat-Armstrong-2013.pdf
Armstrong argues that people have a right to receive and provide (or not provide) care, and unpaid care work is an indicator of equity, because without appropriate supports, demands for unpaid care will increase, which will contribute to gendered inequalities in health and economic well-being in particular. Many supports (respite services, training, workplace accommodations) are helpful yet reinforce women’s responsibility for unpaid care work. Structural supports, particularly from government, are paramount.
Battams, N. (2016, Feb. 18). Family Caregiving in Canada: A Fact of Life and a Human Right. The Vanier Institute of the Family. https://vanierinstitute.ca/family-caregiving-in-canada/
This OpEd style piece by Nathan Battams from the Vanier Institute outlines some of the policy and legal issues surrounding employed family carers and workplace accommodation.
Funk, L. (2019, Dec. 27). It shouldn’t be this hard to navigate health and social care systems. Policy Options. Policy Options, Institute for Research on Public Policy. https://policyoptions.irpp.org/magazines/december-2019/it-shouldnt-be-this-hard-to-navigate-health-and-social-care-systems/
This OpEd draws attention to the need to address the carer burden, stress and frustration that can arise from trying to navigate health and social care systems with and on behalf of older adults. The full report for the Institute for Research on Public Policy is also available, as is a link to a podcast interview.
Linkages Reading List: Caregivers. (2021). https://sagelink.ca/wp-content/uploads/2021/06/Caregivers-Reading-Lists-20210622-SL.pdf
Topics include family caregiving, impact of informal caregiving, chronic illness and caregiving, self-care needs of caregivers, and technology for caregivers. Last reviewed June 2021.
MacCourt, P., & Krawczyk, M. (2012). Supporting Caregivers through Policy: The Caregiver Policy Lens. Vancouver, British Columbia: British Columbia Psychogeriatric Association. https://www.msvu.ca/wp-content/uploads/2020/05/Caregiver20Policy20Lens.pdf
Starting from the argument that public policies tend to overlook effects on or needs of family carers of older adults, and can even contribute to carer burden, the authors propose a framework for assessing and developing policies and programs, from the perspective of care work. The framework is informed by existing research as well as consultation with carers of older adults as well as program managers and policy analysts.
Purkis, M.E., & Ceci, C. (2015). Problematizing care burden research. Ageing and Society, 35(7): 1410–1428. http://dx.doi.org/10.1017/S0144686X14000269.
In this conceptual paper, the authors argue that one of the reasons that existing research on home-based family care work for persons with dementia has had little impact on reducing carer burden, lies in the dominant conceptualization of carer burden, a focus on the carer-care recipient dyad, and a tendency to sidestep the diversity and complexity of care situations.
Sheets, D.J., Black, K., & Kaye, L.W. (2014). Who cares for caregivers? Evidence-based approaches to family support. Journal of Gerontological Social Work, 57(6–7): 525–530. http://dx.doi.org/10.1080/01634372.2014.920606.
In this introduction to a special issue on caregiver support programs (with a particular focus on programs funded by one initiative in the U.S.), the authors note that many existing evidence-based interventions developed under ‘controlled’ scientific conditions are often hampered by implementation in practice in the real-world. The programs they highlight in the special issue, they argue, are efficacious and sensitive to diverse cultural backgrounds of carers.
Stall, N., Keresteci, M., & Rochon, P. (2020, Mar. 13). Family caregivers will be key during the COVID-19 pandemic. Toronto Star. https://www.thestar.com/opinion/contributors/2020/03/31/family-caregivers-will-be-key-during-the-covid-19-pandemic.html
The writers argue that increased needs for care arising because of the COVID-19 pandemic will have a particularly significant effect on family carers, and discuss the need for training, equipment, psychological support, clear communication, and federal employment insurance benefits and protections.
Relevant Websites and Organizations
Alzheimer Society of Canada: Other Resources for Caregivers
The information pages available at this link, designed for family carers of persons with dementia, provide a good overview of some of the everyday challenges that carers face.
Carers Canada, closely affiliated with the Canadian Home Care Association, is a group of partner organizations that in 2000 established this group to increase public awareness of unpaid carers, stimulate collective action, and influence the development of supportive government policies and programs. Their home page currently includes links to help carers navigate COVID-related resources.
The Care Economy Statement
Canada’s crisis in care has been highlighted by the pandemic. The crisis has had terrible consequences for so many, including those in long-term care. Many of the deficiencies have weighed heaviest on women, racialized and Indigenous populations, and those with disabilities. In response, a group of reputable activists and experts are spearheading a movement to put care at the centre of the political agenda. The Care Economy Statement describes the principles for achieving a just recovery that addresses the crisis in care for both those who need and those who provide care. It is a call to recognize that good care is crucial to our health and well-being as individuals and as a society; it is the critical social infrastructure that delivers overall economic stability and growth; and it is a shared responsibility, not just a personal one. This requires a shift from thinking of care as an expenditure to understanding it as an economic driver through investment in people and good jobs. With this shift we create a healthy society that can maximize its potential and excel in new ways.
The Carework Network is an international organization of researchers, policymakers, and advocates involved in various domains of care work. Based in the social sciences, individuals from all academic disciplines and advocacy organizations who take various approaches to the study of care work and care work policy are invited to participate in the Carework Network.
International Alliance of Caregiver Organizations
An international group of carer organizations that aims to highlight unpaid care work as a social and economic policy issue, promote public awareness, and disseminate best practices for supporting carers. See the link to the “Global State of Care” project for a summary of what countries around the world are doing at the policy level.
Manitoba’s Caregiver Recognition Act
Bill 42, introduced in 2011, was the first of its kind in Canada (Ontario and Quebec now have similar legislation), and puts forward eight general principles meant to be promoted by government, including recognizing carers’ contributions and expertise, supporting them and acknowledging their own needs beyond the caring role, and promoting their social participation, health, and economic well-being.
Transformational Responses to COVID-19 (by the CareWorkNetwork)
This virtual hub is a project of the CareWork Network (see below) and is designed to engage people and shape public dialogue around both paid and unpaid care for individuals of all ages, with a feminist and activist focus.
Substance Use and Older Adults
(Chapter 30 by Karen Urbanoski)
Canadian Centre on Substance Use and Addiction. (2018). Improving Quality of Life: Substance Use and Aging. https://www.ccsa.ca/improving-quality-life-substance-use-and-aging-report
A report produced by the Canadian Centre on Substance Use and Addiction that touches on a variety of topics related to substance use among older Canadians.
Canadian Coalition for Seniors’ Mental Health. (2019). Substance Use and Addiction. https://ccsmh.ca/substance-use-addiction/
With its focus on substance use disorders, this resource considers the smaller proportion of people who are experiencing the greatest concentration of harms related to their substance use. It includes separate treatment guidelines for the four psychoactive substances, as well as a helpful introduction that gives an overview of existing evidence and a summary of the methods used by the Coalition in generating the clinical guidelines.
Canadian Institute for Substance Use Research. (2017). Understanding Substance Use: A Health Promotion Perspective. https://www.heretohelp.bc.ca/infosheet/understanding-substance-use-a-health-promotion-perspective
Discusses key issues in substance use from the lens of health promotion, offering a balanced overview of why people use psychoactive substances and what health promotion practitioners and individuals can do to support their health.
Government of Canada. (2018). Strengthening Canada’s Approach to Substance Use Issues. https://www.canada.ca/en/health-canada/services/substance-use/canadian-drugs-substances-strategy/strengthening-canada-approach-substance-use-issue.html
A report produced by Health Canada on the Canadian Drugs and Substances Strategy and a summary of evidence on the determinants and policy responses to substance use.
Linkages Reading List: Cannabis and the Older Adult. (2019). https://sagelink.ca/wp-content/uploads/2020/01/Cannabis-and-the-Older-Adult.pdf
Topics include efficacy and safety, evidence and recommendations, neurocognitive effects, and use in those with dementia. Last reviewed December 2019.
Linkages Reading List: Optimizing Medications in Older Adults. (2019). https://sagelink.ca/wp-content/uploads/2020/01/Optimizing-Medications-in-Older-Adults.pdf
Topics include safety, inappropriate prescribing, and deprescribing. Last reviewed December 2019.
Linkages Reading List: Substance Misuse in Older Adults. (2020). https://sagelink.ca/wp-content/uploads/2020/11/Substance-Misuse-Reading-Lists-20201124.pdf
Topics include guidelines on opioid use, benzodiazepine use, alcohol use, assessment, and age-specific considerations for addiction. Last reviewed November 2020.
Sloboda, Z., Petras, H., Robertson, E., Hingson, R. eds. (2019). Prevention of Substance Use. Springer.
An edited text that comprehensively covers the key elements of prevention science related to substance use and population health globally. Includes chapters focused on the development of substance use and related problems, policy and individual-level interventions, research methods in prevention science, and ethical issues.
Relevant Websites and Organizations
The Canadian Academy of Psychiatric Epidemiology
The Canadian Academy of Psychiatric Epidemiology is an organization of academic researchers from multiple disciplines who investigate the distribution, determinants, and impacts of mental illness and substance use.
Canadian Centre on Substance Use and Addiction
For information on substance use, including research reports, webinars, infographics and other educational materials – all with a Canadian focus. Hosts a subscription-based news service for those who want to stay on top of Canadian trends and events.
Canadian Coalition for Seniors’ Mental Health (CCSMH): Guidelines on Substance Use Disorders Among Older Adults
The mission of the CCSMH is to promote the mental health of seniors by connecting people, ideas and resources. In 2017, the CCSMH was awarded funding by Health Canada to develop four sets of clinical guidelines on the prevention, screening, assessment, and treatment of Alcohol Use Disorder Benzodiazepine Receptor Agonist Use Disorder, Cannabis Use Disorder and Opioid Use Disorder in older adults.
Deprescribing App hosted by the Bruyère Research Institute and the Centre de recherché, Institut universitaire de gériatrie de Montréal
For information on deprescribing, with a wealth of resources tailored for patients, caregivers, service providers, and researchers. Includes a blog, as well as links to educational modules, web-based tools, publications, and webinars.
World Health Organization: Alcohol, Drugs and Addictive Behaviours Unit
For information on psychoactive substance use globally, including up to date evidence on policies, treatment, and public health strategies. Publications include fact sheets and infographics, research reports, and information from international meetings of experts.
Death and Dying
(Chapter 31 by Katherine Arnup and Nathan Battams and Personal Reflection 6 by Barry Worsfold)
Arnup, K. (2015). “I Don't Have Time for This!”: A Compassionate Guide to Caring for Your Parents and Yourself. Life Changes Press.
A thoughtful and informative guide to beginning essential conversations with our parents about the end of life, tools and strategies for caregiving, keys to releasing guilt and regret, advice about asking for and receiving help, and the positive impact that facing aging, illness and death can have on our lives (and those around us).
Arnup, K. (2018). Family Perspectives: Death and Dying in Canada. The Vanier Institute of the Family. https://vanierinstitute.ca/family-perspectives-death-and-dying-in-canada/
A 2018 report from The Vanier Institute of the Family that examines the evolution of death and dying across generations, the desires and realities of families surrounding death and dying, the role of families in end-of-life care, and its impact on well-being.
Carter, C. (2019). What it’s really like to die at home in Ontario. Healthy Debate. https://healthydebate.ca/2019/06/topic/dying-at-home/.
An article published in Healthy Debate that discusses the experiences and realities of dying at home. Weaving together stories and current research on end-of-life care, her article provides evidence-based insight on the experiences of people dying at home and those who care for them.
Clanchy, K. (2021). Letting go: My battle to help my parents die a good death. The Guardian. https://www.theguardian.com/news/2021/apr/06/letting-go-my-battle-to-help-my-parents-die-a-good-death
In this touching and detailed article, Kate Clanchy tells the story of her parents’ deaths from COVID-19 and their efforts to get the system to pay attention to their Advance Decision documents and their desire to die together at home.
Frazee, C. (2014, Oct. 14). There can be dignity in all states of life. Ottawa Citizen. https://ottawacitizen.com/news/national/catherine-frazee-there-can-be-dignity-in-all-states-of-life
An op-ed by educator, researcher and disability rights activist Catherine Frazee, OC, on the concept of dignity within the discussion of medically assisted dying.
Funnell, S., Walker, J., Letendre, A. et al. (2021). Places of death and places of care for Indigenous Peoples in Ontario: A retrospective cohort study. Canadian Journal of Public Health, 112, 685–696. https://doi.org/10.17269/s41997-021-00482-y
Most people, including Indigenous people in Ontario, wish to die in their communities. How often Indigenous people in Ontario die in their preferred settings is unknown. This study aims to describe the places of care and death for Indigenous people in Ontario who received provincially funded home care services.
Gawande, A. (2017). Being Mortal: Medicine and What Matters in the End. Picador, Macmillan Publishing.
Medicine has triumphed in modern times, but when it comes to the inescapable realities of aging and death, what medicine can do often runs counter to what it should. Through eye-opening research and gripping stories of his own patients and family, Gawande reveals the suffering this dynamic has produced. Nursing homes, devoted above all to safety, battle with residents over the food they are allowed to eat and the choices they are allowed to make. Doctors, uncomfortable discussing patients’ anxieties about death, fall back on false hopes and treatments that are actually shortening lives instead of improving them. Gawande, a practicing surgeon, examines medicine’s ultimate limitations and failures—in his own practices as well as others’—as life draws to a close. Riveting, honest, and humane, Being Mortal shows how the ultimate goal is not a good death but a good life—all the way to the very end.
Linkages Reading List: Advance Care Planning and End-of-Life Considerations. (2020). https://sagelink.ca/wp-content/uploads/2020/01/Advance-Care-Planning-End-of-Life-Considerations.pdf
Linkages Reading List: End-of-Life. (2020). https://sagelink.ca/wp-content/uploads/2020/01/End-of-Life.pdf
Topics include advance care planning, decision making, communication, hospice, palliative care, palliative sedation, euthanasia and assisted suicide, caregiver experiences, socio-cultural considerations, and delirium at end-of-life. Last reviewed January 2020.
Mirabelli, A. (2018). Hub Hospice and the Palliative Care Experience. The Vanier Institute of the Family. https://vanierinstitute.ca/alan-mirabelli-hub-hospice-and-the-palliative-care-experience/.
The final presentation delivered by Alan Mirabelli, former Executive Director of Administration at the Vanier Institute of the Family, at Hub Hospice Palliative Care, a unique community-based hospice-at-home organization in Almonte, Ontario. Alan shares his thoughts on the importance and impact of palliative and end-of-life care.
Thompson, M. (2021, June). The Choice: An unnecessary moral dilemma. Fifty-Five Plus magazine. https://console.virtualpaper.com/fifty-five-plus-magazine/ottawa-june-55-2021/preview/#48/
Margaret Thompson, a retired teacher, writes about her experience with losing a parent in long-term care during the COVID-19 pandemic. Her honest, heart-rending story is a personal one, but it also speaks to the bigger picture of our societal and systemic failure to protect our oldest and most vulnerable citizens living in retirement and long-term care homes. Margaret’s feelings of despair, grief and guilt over the circumstances surrounding her mother’s death and the difficult mourning process that follows are shared by many others who have lost loved ones.
Relevant Websites and Organizations
Canadian Virtual Hospice
The Canadian Virtual Hospice provides support and personalized information about advanced illness, palliative care, loss and grief, to people living with illness, family members, people working in healthcare, educators, and researchers. The Canadian Virtual Hospice is a division of the International Centre for Dignity and Palliative Care Inc., a registered charity (from the Virtual Hospice website).
The official website for the original death café social enterprise. Death Café facilitates directed discussions on death to “increase awareness of death with a view to helping people make the most of their (finite) lives”.
Epstein, R., & Friedman, J., directors. (2018). End Game. Netflix. (40 minutes). https://www.netflix.com/ca/title/80210691
A 2018 documentary from Academy Award winning filmmakers Rob Epstein and Jeffrey Friedman tells the stories of three medical providers trying to change the way people think and make choices about end of life.
Fong, E. (2017). My mother's final wish—and the right to die with dignity. TED Talk. (21 minutes). https://www.ted.com/talks/elaine_fong_my_mother_s_final_wish_and_the_right_to_die_with_dignity?rss=172BB350-0207
After a terminal cancer diagnosis upended 12 years of remission, all Elaine Fong’s mother wanted was a peaceful end of life. What she received instead became a fight for the right to decide when. Fong shares the heart-rending journey to honor her mother’s choice for a death with dignity—and reflects on the need to explore our relationship to dying so that we may redesign this final and most universal of human experiences.
Krauss, D., director. (2016). Extremis. Netflix. (24 minutes). https://www.netflix.com/ca/title/80106307
A 2016 documentary that follows a palliative care specialist at Highland Hospital in Oakland, California as she manages a team helping terminal patients as they prepare to die. Extremis highlights the experiences of patients and their families at end of life, the tensions they experience, and difficult decisions doctors, patients, and families have to make.
Miller, B. J. (2015). What Really Matters at the End of Life. TED Talk. (19 minutes). https://www.ted.com/talks/bj_miller_what_really_matters_at_the_end_of_life.
At the end of our lives, what do we most wish for? For many, it's simply comfort, respect, love. BJ Miller is a hospice and palliative medicine physician who thinks deeply about how to create a dignified, graceful end of life for his patients. Take the time to savor this moving talk, which asks big questions about how we think on death and honor life (description from the Ted Talks website).