Michael Gordon, MD, MSc, FRCPC, FRCP Edin, Medical Program Director, Palliative Care, Baycrest Geriatric Health Care System; Professor of Medicine, University of Toronto, Toronto, ON.
Natalie Baker, MSc, Project Coordinator, Baycrest Geriatric Health Care System, Toronto, On.

Abstract
Physicians and other health care providers have learned to approach end-of-life care issues in individuals suffering from malignant disease quite effectively. Palliative approaches are widely accepted for this population. In contrast, individuals suffering from end-stage dementia may also benefit from suitably tailored palliative care which is much less often considered or provided. It is incumbent on health care professionals responsible for treating those with end-stage dementia to offer palliative care. This must be preceded by proper discussions between afflicted individuals, their families and their health care providers to assure that they understand the progress and prognosis of end-stage dementia.
Keywords: dementia, palliative care, end-of-life care.

Mary Anne Huggins, MD, CCFP, DABHPC, Palliative Care Services, Toronto General Hospital, University Health Network; Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, ON.
Laura Brooks, BScN, MScN, ACNP, Palliative Care Services, Toronto General Hospital, University Health Network, Toronto, ON.

Discussing end-of-life care with older patients is very important, as it ensures their preferences are known and they retain control over their care decisions even when they may no longer be actively involved in them. Unfortunately, these discussions do not always occur, and when they do occur, they are not always done well. There are patient and physician barriers to advanced care planning. Physicians may lack the skills necessary to accomplish the task of making decisions for future care. In this article we discuss advanced care planning, its importance as well as related challenges and barriers. We then outline a practical approach to advanced care planning for older adults.
Key words: end-of-life care, advance directives, advanced care planning, living wills, substitute decision-maker.

Rory Fisher, MB, FRCP(Ed)(C), Professor Emeritus, Department of Medicine, University of Toronto and The Regional Geriatric Program of Toronto, Toronto, ON.

Euthanasia and assisted suicide are attracting increasing public interest. The experiences in the Netherlands and Oregon are explored as well as the topics of terminal sedation and voluntary dehydration. The reasons for requests for euthanasia are broadening beyond medical issues. Reasons for and against are presented. Recommendations are made to improve care of the dying and the frail elderly to decrease the perceived need for euthanasia. If changes are made to legalize euthanasia and/or assisted suicide in Canada, there will be a need to protect conscientious objectors.
Key words: euthanasia, physician-assisted suicide, terminal sedation, end-of-life care, conscientious objectors.

Lucia Gagliese, PHD, CIHR New Investigator, School of Kinesiology and Health Sciences, York University; Department of Anesthesia, University Health Network; Department of Anesthesia and Psychiatry, University of Toronto, Toronto, ON.
Rinat Nissim, MA, PhD Candidate, Department of Psychology, York University; Doctoral Fellow, Psychosocial Oncology & Palliative Care, University Health Network, Toronto, ON.
Melissa Jovellanos, BSc, MSc Candidate, School of Kinesiology and Health Sciences, York University; Department of Anesthesia, University Health Network, Toronto, ON.
Nataly Weizblit, BSc Candidate, Department of Psychology, York University; Department of Anesthesia, University Health Network, Toronto, ON.
Wendy Ellis, RN, Clinical Research Co-ordinator, Department of Anesthesia, University Health Network, Toronto, ON.
Michelle M. Martin, PhD, Postdoctoral Fellow, Department of Anesthesia, University Health Network, Toronto, ON.
Gary Rodin, MD, Professor, Department of Psychiatry, Director, Psychosocial Oncology & Palliative Care, Joint University of Toronto/University Health Network; Harold and Shirley Lederman Chair in Psychosocial Oncology and Palliative Care, Toronto, ON.

Both older adults and minority patients are at risk of undertreatment and mismanagement of pain. Caregivers report that many older adults are in pain before death, and doctors are often less willing to prescribe strong opioids to the dying. Underutilization of narcotics with older minority populations has also been reported. The Canadian population is aging rapidly, and Canada is home to one of the most ethnically diverse cities in North America. In this context, the above findings are unacceptable. Recommendations for improvements in the health care system are made.
Key words: end-of-life care, pain management, racial disparities.

Loren K. Mell, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Arno J. Mundt, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Radiation therapy (RT) is commonly used in the treatment of older cancer patients. RT may be used as definitive therapy for benign or malignant tumours, as adjuvant therapy with surgery and/or chemotherapy, as palliative therapy when cure is no longer possible, and as alternative to surgery in patients with multiple comorbidities. However, RT is often not given to older patients who might benefit from it, due to biases, misapprehensions about potential toxicity, and social factors particular to this patient population. The preponderance of data suggest that RT is well tolerated in older adults and treatment decisions should be based on prognostic factors irrespective of age. Emerging RT technologies may particularly benefit aged patients by reducing potential toxicities, shortening treatment times, and improving tumour control.

Key words: age, radiation therapy, toxicity, cancer, procedures.

Rory Fisher, MB, FRCP(Ed)(C), Professor Emeritus, Department of Medicine, University of Toronto, Toronto, ON.

Eoin Connolly, MA, Clinical Ethics Fellow, Joint Centre for Bioethics, University of Toronto, Toronto, ON.

Canada's aging population makes appropriate end-of-life care a priority. Alzheimer's disease and related dementias become increasingly common with aging. The terminal stages are characterized by severe cognitive and physical incapacity with a poor prognosis. Artificial nutrition and hydration may be provided by feeding tubes; however, there is no
evidence of benefit, and there are significant side effects to be considered. Barriers to appropriate end-of-life decision making are identified, and current evidence indicates that this patient population should be treated with appropriate palliative care.

Key words: Alzheimer’s disease, artificial nutrition and hydration, dementia, end-of-life care, ethics.