Recent years have seen significant improvement in the provision of palliative and end-of-life care, with communication between health professionals, the patient and their family at the core of a positive end-of-life experience.  There is concern that despite improvements in care, discussion of end-of-life planning is not always delivered in a timely manner, may be ineffective or of poor quality. [1,4,5]
This review aims to discuss the evidence for timely initiation of end-of-life discussion and how older adults would prefer to receive this information.
A significant number of older adults with non-malignant but progressive and life-limiting conditions receive palliative and end-of-life care.  The importance of good communication in the end-of-life phase has long been recognised by health care providers and has been shown to improve patient and family understanding, enhance therapeutic relationships, facilitate access to appropriate services, increase compliance with treatment, and improve overall quality of life for the older adult. [1,2]
It appears that end-of-life conversations occur readily with older adults who have a diagnosed malignancy where the prognosis is more easily measurable.  This is not always the case for older people with non-malignant illness with unpredictable end-of-life trajectories. Research suggests that most but not all older adults would like the opportunity to discuss their end-of-life needs, and that these discussions should happen even in the absence of illness and predicted trajectory to death. [3,4] This is particularly relevant as there are an increasing number of frail elderly with significant comorbidity and challenging health care needs. 
The literature states that health professionals should initiate end-of-life discussions without defining which health professional should assume this responsibility or at what point in time.  Nominating a key health professional with whom the person feels comfortable and with whom he or she will have regular contact could assist in reducing anxiety and confusion in the older adult. [1,3] Offering multiple occasions to discuss end-of-life care may be important as studies show that health professionals often perceive themselves to have provided prognostic information more often than patients’ reported receiving it. [3,5] Older adults may want practical information on how their condition will affect activities of daily living and what to expect as health deteriorates, but may not want prognostic information. [5,6]
The desire and need for information may be significantly different for the person receiving palliative care compared to the family and carer(s).  These changes present challenges to the team providing palliative care. A certain percentage of older people feel that end-of-life discussions should be a routine component of healthcare yet the same review showed that older people discuss terminal care with family members more than with their doctor.  Other research indicates that advance care conversations presented as a person’s right could encourage people to seek out information to help make informed decisions.  This may not be realistic for frail older people. 
Patient understanding of their disease is shown to be helpful in reconciling the subsequent prognosis. It is also important to consider the timing, individual readiness and volume and type of information provided as well as the environment information is delivered in. [2,3,5]
Page updated 24 May 2017