Am I Old Yet? , (Komaiko, 1999), is a true story that takes us deep into a world most hope to never enter and few dare to go: the nursing home. After reading this book, end-of-life care, an issue that was once just an aspect of nursing to me became a powerful issue that needs prompt attention and change. According to Leah Komaiko (1999), the truth about aging lies in the idea that no matter how old a person is, if they have love and personal relationships at the end of their lives, there is only one age: alive.

This statement motivated me to research the issue of end-of-life care, only to be left with a drive to change the present practices and improve the quality of life of the individuals who tend to be thrown into one homogeneous group. We as health care providers seemingly forget the uniqueness and individualized needs and desires of the elderly. The population of the United States is growing older; a phenomenon widely noted that carries significant implications for the nation's health, social, and economic institutions. According to the National Academy of Sciences (2000), more than 34 million Americans (12% of the population) are aged 65 and older.

Within the United States, the size of the population over age 65 has soared during this century, increasing from 3 million in 1990 to 34.3 million today. Since 1940, the population of people over 65 has tripled and is projected to more than double again by 2050. A major concern today that is both related to and affected by this phenomenon is quality of end-of-life care. A burning question that is the investigation of much research today done on nursing homes is: are residents receiving quality end-of-life care, and if not, why. So if the concern is already established, it is of great importance and demand to correct the issue before it exacerbates with the growing population. The challenges of this demographic are dramatic and we must ensure that we are fully prepared to meet them.

It is necessary to understand the future size of the older population to identify their extent of services and the extent to which those demands can be met. In Komaiko's book (1999), she dives into the world of nursing home residents, and plays a particular role in the life of one woman, Adele. She adopts an elder through a program provided by the nursing home. In the beginning she could only see how meaningless these people's lives were. They would sit in chairs, staring for hours at "nothing". They would line up like herds of animals for dinner at the same exact time each day.

They would all speak of their families and anticipate a visit from someone, only leaving them disappointed at the end of each day when that door never opened, and if it did the only people who ever walked through it were the nurses, that to them, "didn't care". They all had complaints of not being cared for, felt they were treated like children, and most importantly, they felt alone. After spending an hour a week with Adele for a period of six months, Komaiko saw a different side of the residents of this nursing home. They were individuals who were unique, accomplished, intelligent, and "alive" in ways she could never imagine. These characteristics were brought out in the residents after Leah showed she cared, by forming personal relationships with residents. She talked to them and attended social gatherings with them making them feel important and like individuals who still had "life" in them.

Being that most of the residents had no one to contribute to their emotional well being, Leah provided this by just listening and being a friend. Approximately 20% of deaths in the United States occur in nursing homes, thus there has been much research on palliative, end-of-life care in nursing homes and the majority of the research findings suggest that there is room for improvement. According to Singer (1999), because everyone dies, end-of-life care is among the most prevalent issues in health care today. It is evident through studies done on both health care providers and patients that there is room for and a need for improvement.

In a recent study of end-of-life care, Travis (2002), noted through analysis of patient care that there is a major problem with palliative care. A hierarchy of obstacles exists in long-term care settings that begins with the lack of recognition that restorative, rehabilitative, or current treatment futility has commenced. Main problematic areas included lack of communication among decision makers, no agreement on a course of care, failure to implement timely plan of care, and lack of palliative care education. A fundamental study that looked at the patients' perspective of quality end-of-life care drives straight into the issue at hand. Singer (1999), identified and described the elements of quality of life care from the patients' eyes. The results showed that there were five domains of quality care which are the most important areas and also the most lacking in the care they are given.

The identified domains were, receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving sense of control, relieving burden, and most significantly, strengthening relationships with others including loved ones. These domains, which characterize patients' perspectives on end-of life care should serve as a focal point for improving quality of end-of-life care. Although numerous other studies could be presented to strengthen the argument that there is an eminent problem facing healthcare today; looking at the patients' perspective alone serves as enough evidence that there is a problem. The patients are the people who should have a say in how they should be cared for at the end of their lives.

Thus, with evidence of the existing problem, knowledge of the problem and it's contributing factors, what can be done to overcome this obstacle. Tomorrow's resident care should be focused on quality of life rather than just "living". Komaiko stated in Am I Old Yet? (1999), "living" has a very different meaning than "being alive".

I propose that the future of end-of-life care should be driven by a movement toward practical application of personal resident-directed / centered care. The management of the issue at hand involves a fundamentally different structure of care in nursing homes. Education initiatives is a key area to focus on in order to attain this new structure and "fix" the problem. According to the Ideas Institute (2002), traditionally, nursing homes have been organized around the efficient provision of physical care to frail and elderly impaired individuals. (Ideas Institute, 2002) This is where the change needs to be made. Nursing homes should not only provide physical care, but also care for quality of life.

For this change to take place and be successful, first and foremost nurses and other health care professionals who play a key role in advancing improvements in end-of-life care, should be educated regarding the special needs of this aging population. Older persons have many unique needs in comparison to the younger population. Thus special training is imperative to treat the elderly population. We must address the emotional needs that the elders report they are "missing" in their end-of-life care. Calkins (2002) supports the idea that education of health care providers is essential in improving quality care.

Education should focus on the positive aspects of personhood and recognize elders' residual strengths and abilities to engage in meaningful relationships that have purpose. The educational focus should be on psychological needs of elders, including their many strengths, not just their weaknesses and failings. (Calkins, 2002) The American Association of Colleges of Nursing (2002), describes the problem and the solution to the problem as the following: Individuals live until the moment of death; that care until death may be offered by a variety of professionals; attention must be given to the physical, psychological, social, and spiritual concerns of the patient. Thus educational preparation to provide this care is imperative. However, educational preparation for end-of-life care has been inconsistent and sometimes neglected within nursing curricula. Given the likelihood that care will be given by a variety of health care professionals, it is essential that such preparation be interdisciplinary in its approach to preparing students for the end-of-life practice in which they will engage.

This supports my proposal that management of this problem lies in education. As nurses we should have an in-depth understanding of the needs of every population. In this case the elderly population. With proper education we can provide adequate care for the elderly, a large part of our population that is quietly crying or help. In summary, after reading Am I old yet? (1999), I was given a brief glimpse into the world of the elderly population.

I learned that end-of-life care is so important to "living". The impact of the friendship and personal relationship between Adele and Komaiko showed that the elderly can still live life to the fullest even in their last days. The miracle of life is not over until it is truly over. Even with progress towards quality of nursing care for our growing population of elderly, work remains to be done. My hopes are that with the proposed solution of more education regarding elderly and their emotional needs, the challenge facing us can be disseminated and all individuals, even the eldest, will be given every opportunity to feel "alive". American Association of Colleges of Nursing.

(2002). Peaceful Death: Recommended Competencies of Curricular Guidelines for End-Of-Life Nursing Care. Washington, DC: American Nurses Publishing. web Institute. (2002). The nursing home of the future: are you ready?

In Providing solutions that improve the life of older adults. Komaiko, L. (1999). Am I old yet? a true story of a timeless friendship. New York, NY: St. Martin's Griffen.

The National Academy of Sciences. (2000). The Aging Population in the Twenty-First Century: Statistics for Health Policy. Singer, P.A., Martin, D.K., & Keller, M. (1999). Quality end-of-life care: patients' perspectives. Journal Of American Medical Association, 281,163-168.

Travis, S.S., Bernard, M., Dixon, S. & McAuley, W.J. (2002). Obstacles to palliation and end-of-life care in a long term care facility. Gerontologist, 42,342-349.