Healthcare of Older People

The nature of illness in older people greatly influences the ethical issues in their healthcare. Older people have a higher burden of illness than younger people. On average, they are likely to have several chronic medical conditions, be on multiple medications, and have frequent encounters with the healthcare system, including more hospitalizations. Because older people are closer to the end of their life expectancy, they have a greater chance of being involved in situations where difficult healthcare decisions must be made. Decisions about the appropriate use of life-sustaining medical treatment for older patients are commonplace. These range from Do-Not-Resuscitate (DNR) orders, to decisions to discontinue dialysis, to decisions about withholding or withdrawing artificial nutrition and hydration. Many, if not most, deaths in healthcare institutions in the United States are preceded by explicit decisions to limit treatment. These treatment limitation decisions, more properly viewed as decisions to change to a palliative care plan from life-sustaining or death-delaying efforts, are generally more common in the care of older people.

While any individual may become incompetent during a critical illness, older people are at greater risk of impaired decision-making capacity because of either a transient delirium or a chronic dementing illness, such as Alzheimer's disease, which results in permanent cognitive impairment. Thus, older people are not only at risk of having end-of-life decisions made in the healthcare setting; they frequently are not capable of making those decisions themselves at the time required. In such situations, physicians routinely turn to the family of an older person to serve as a surrogate decision maker or proxy. Several studies of the treatment preferences of older patients and their potential proxies (spouses, children, and physicians), like that of Allison Seckler and her colleagues in 1991, have uncovered serious discord between the choices that would be made by patients and by their proxies. While this raises concerns about the validity of proxy decision making vis-à-vis its accuracy as a substituted judgment, one can argue that family members are still appropriate surrogates and that many older people care more about who makes decisions for them than about the exact decisions being made.

The foreseeability of both serious illness and the loss of competency for older people, as well as questions about proxy decision making, have created a strong interest in the use of advance directives in the care of older people. Advance directives include instructional documents, such as living wills, and proxy appointment documents, such as the durable power of attorney for healthcare. Interestingly, most of the empirical studies done on both proxy decision making and advance directives have focused on older people. Advance directives have received increasing attention in the United States with the 1991 enactment of the Patient Self-Determination Act, a federal law requiring healthcare institutions to educate patients about the availability and use of these instruments. While it is hoped that these efforts will increase the number of older people giving advance instructions for their healthcare, it remains to be seen if older people will execute advance directives in significant numbers, and if physicians will respect the preferences outlined in these documents. Data from the 1997 SUPPORT study cast doubt on the effectiveness of advance directives.

Because of its effects on the competency of older individuals, dementia occasions significant ethical dilemmas as discussed by Greg Sachs and Christine Cassel in their article on the subject. Dementia affects perhaps as high a proportion as 10.3 percent of individuals over age sixty-five and 47 percent of those over age eighty-five, and raises ethical concerns for several reasons. First, rather than presuming competence and working within the bounds of confidentiality, truth telling, and patient autonomy expected in the normal doctor-patient dyad, when the patient has dementia, the doctor-patient relationship is altered in a fundamental fashion. A physician caring for an older person with dementia must reassess decision-making capacity frequently, carefully evaluate what the patient says for useful information, weigh what can be shared with the patient, and rely on others for information and assistance in executing a care plan. Second, the progressive and irreversible nature of the most prevalent kinds of dementia alters the goals of medical care of the patient with dementia. While promising research on dementia continues, existing treatments provide only modest benefits and there are no therapies that will either arrest or cure progressive dementias. As with hospice care or rehabilitation medicine, many, including Nicholas Rango, argue that the medical care of a patient with dementia properly focuses on maximizing function, including socialization, palliation of symptoms, maintaining hygiene, and preserving dignity. Third, the family members of an older person with dementia are not only proxies for decision making, they also usually provide the bulk of their relative's daily care needs. The great burden of caregiving places family members at risk of depression and other illness, causing health professionals to consider the psychosocial needs of the family as well as the patient.

While only about 5 percent of people over the age of sixty-five are in a nursing home at any one time, in 1991 Peter Kemper and Christopher Murtaugh estimated that the lifetime risk of spending time in a nursing home in the United States is as high as 40 percent. Thus, many older people do receive medical care in a nursing home for some portion of their lives and it is the location of death for an increasing number of older Americans, as noted by Joan Teno in 2002. At least in the United States, nursing home care frequently has been cited more for its deficiencies: unwarranted mechanical restraint of residents, inattention to treatable conditions such as urinary incontinence, and inappropriate and excessive use of psychotropic medications. At least part of the problem of poor nursing home care has been the lack of continuity in medical care of older people once they enter a nursing home. A minority of physicians in the United States visits their older patients once the patients enter a nursing home (as few as 28% in one U.S. nationwide study), according to research by Janet Mitchell and Helene Hewes. Subspecialty care, including psychiatry, is even less available to older people residing in nursing homes. On a more positive note, in 1997 Catherine Hawes and her colleagues noted that changes in nursing home regulations do appear to be having beneficial effects on many aspects of the quality of nursing home care.

Problems with access to good medical care for nursing home residents are actually a subset of the larger problem of the level of expertise in the medical care of all older people. While geriatrics is an established specialty in the United Kingdom, a subspecialty certifying exam in geriatric medicine in the United States was offered for the first time only in 1988. Very few physicians enter fellowship programs that provide postresidency training in geriatric medicine. In his study of these programs, David Reuben contends that the shortage of fellowship-trained geriatricians remains a significant challenge despite changes made in the late 1990s to shorten the duration of training required for certification (Reuben).

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