Treatment ethics, quality of life and health economics in the management of hematopoietic malignancies in older patients.

The prevalence of diseases such as AML or myelodysplastic syndromes increases with the aging of the population. Only intensive chemotherapy or hematopoietic cell transplantation have curative potential. However, comorbid conditions may interfere with effective therapy. Although transplantation following low-intensity conditioning is being carried out in patients even in their 70s, these are highly selected patients, and the data cannot be extrapolated to the population at large. Further, such a therapy in older individuals may be associated with considerable morbidity and the need for prolonged hospitalization and rehabilitation, stressing the system and draining family resources. As the focus of many older individuals is on quality of life, it is important to emphasize that, for various advanced malignancies, emerging data indicate that quality of life may be better and survival may be longer with palliative care. A re-assessment of treatment decisions in older patients is in order. We tend to 'oversell', and particularly older patients do not have a full understanding of the impact of the proposed therapy on their lives. Our conversations with these patients must include a discussion of supportive/palliative care and must address end-of-life issues. Talking about death may mean talking about life.