End of Life
End of Life
According to IOM (2008), the next generation of older adults will be like no other before it. It will be the most educated and diverse group of older adults in the nation’s history. They will set themselves apart from their predecessors by having fewer children, higher divorce rates, and a lower likelihood of living in poverty. But the key distinguishing feature of the next generation of older Americans will be their vast numbers. According to the most recent census numbers, there are now 78 million Americans who were born between 1946 and 1964.
By 2030 the youngest members of the baby boom generation will be at least 65, and the number of older adults 65 years and older in the United States is expected to be more than 70 million, or almost double the nearly 37 million older adults alive in 2005. The number of the “oldest old,” those who are 80 and over, is also expected to nearly double, from 11 million to 20 million (Institute of Medicine of the National Academies [IOM], 2008, p. 29). The United States health care system faces enormous challenges as the baby boomer generation nears retirement age.
Current reimbursement policies, workforce practices, and resource allocations all need to be re-evaluated, and redesigned in order to prepare the health care system for meeting the needs of the inevitably growing population of older adults. Areas such as education, training, recruitment, and retention of the health care workforce serving older adults will require remodeling. To accomplish this will require the dedication and allocation of greater financial resources, even at a time when budgets are already be severely stretched.
“The nation is responsible for ensuring that older adults will be cared for by a health care workforce prepared to provide high-quality care. If current Medicare and Medicaid policies and workforce trends continue, the nation will fail to meet this responsibility. Throwing more money into a system that is not designed to deliver high-quality, cost-effective care or to facilitate the development of an appropriate workforce would be a largely wasted effort” (IOM, 2008, p. 1-12). Ethical Standards for Resource Allocation
Ethics have a paramount role in solving the complex dilemmas surrounding the aging population and health care. There are several ethical standards I believe should be used in determining resource allocation for the aging population and end of life care. Yet realistically, most are unreasonable with the already limited resources available for health care. Unfortunately difficult decisions need to be made in the allocation of resources. Three primary ethical standards that could realistically improve health care for the aging, which I believe should determine resource allocations are: 1.
Autonomy: suggest that individuals have a right to determine what is in their own best interest, though that interest may be limited if exercising that right limits the rights of others. 2. Beneficence: means that clinicians should act completely in the interest of their patients. Compassion; taking positive action to help others; desire to do good; core principle of our patient advocacy. 3. Justice: implies fairness and that all groups have an equal right to clinical services regardless of race, gender, age, income, or any other characteristic (Teutsch & Rechel, 2012, p.
1). It is inevitable that difficult decisions have to be made regarding how health care resources will be allocated for the aging and dying. In my opinion scarce health care resources should be offered as fair as possible (justice), to do the most good for the patient in every situation (beneficence), with respect of the individual human right to have control of what happens to their own body (autonomy). Elderly and end of life patients have a right to care that is dignified and honest.
The three ethical standards noted above should be the driving force behind determining health care resource allocations, allowing for quality care delivery, tailored to individual health needs at any stage of “aging” through the end of life, ensuring protection and satisfaction to such a vulnerable patient population. As stated by Maddox (1998), perhaps the impact of the array of problems, issues, and the myriad difficult decisions that policymakers and managers make may be softened by imaginative and rational strategies to finance, organize, and deliver health care when resources are scarce.
Decisions related to scarce resource allocations must be made in consideration of the ethical principles of autonomy, beneficence, and especially justice. Ethical issues related to scarce resource allocation are likely to become increasingly complex in the future. Thus, it is imperative that health care leaders diligently and ethically continue to explore these issues (Maddox, 1998, p. 41). Somehow, while using the three standards noted, we need to reform our health care system to benefit the aging and dying, and adhere to the codes of conduct the best way possible with the limited resources available.
If there is a will, there is a way! Ethical Challenges The critically challenging ethical issue of “aged based health care rationing” is faced when preparing for an adequate health care system that will meet the care needs of the aging and dying. According to AAM (1988), the rationale for a program of health care rationing based on age rests on the assumption that society should allocate its resources efficiently, and that age-based rationing represents the most efficient method of resource allocation. Within this context, it has been argued that since most of the elderly are not in the work force they do not directly benefit society.
Although the elderly, it is argued, should be provided with basic necessities and comfort, the greatest portion of health care resources, including expensive medical technologies, are better deployed on younger, more productive segments of the population (American Medical Association [AMA], 1988, p. 1). One tool developed by economist that has been used to measure value of ones life so to speak is known as “quality adjusted life years or QALY”. It is a widely used measure of health improvement that is used to guide health-care resource allocation decisions.
The QALY was originally developed as a measure of health effectiveness for cost-effectiveness analysis, a method intended to aid decision-makers charged with allocating scarce resources across competing health-care program (Kovner & Knickman, 2011, p. 258). Another common term for health care rationing is known as the “death panel, or Obama Death Council”. This panel is a government agency that would decide who would receive health care and who would not receive health care based on some form of standard implemented by the government.
One difficult ethical question posed is, if we do ration health care, who decides how it is rationed, when and why? The advocates of rationing argue that society benefits from the increase in economic productivity that results when medical resources are diverted from an elderly, retired population to those younger members of society who are more likely to be working. As stated by Binstock (200), promoting age-based rationing is detrimental to the elderly because it devalues the status of older people and caters to the values of a youth- oriented culture, a
culture in which negative stereotyping based on age is prevalent. One possible consequence of denying health care to elderly persons is what it might do to the quality of life for all of us as we approach the “too old for health care” category. Societal acceptance of the notion that elderly people are unworthy of having their lives saved could markedly shape our general outlook toward the meaning and value of our lives in old age. At the least it might engender the unnecessarily gloomy prospect that old age should be anticipated and experienced as a stage in which the quality of life is low.
The specter of morbidity and decline could be pervasive and over- whelming (Binstock, 2007, p. 8). Other ethical challenges related to the provisions of aging based health care are: 1. Lack of education amongst health care providers in meeting the care needs of the aging and dying as well as providers faced with ethically challenging decisions especially at the end of life. 2. Lack of funds to support the diverse and challenging health needs of the aging, and promotion of comfort when dying, whether it be funds for care, facility placement, or ability to hire enough staff to me the high demands of a large population, and education.
3. Cost effectiveness vs. quality of care vs. quality of life “In the end, there is no “solution” to the problem of aging, at least no solution that a civilized society could ever tolerate. Rather, our task is to do the best we can with the world as it is, improving what we can but especially avoiding as much as possible the greatest evils and miseries of living with old age: namely, the temptation of betrayal, the illusion of perpetual youth, the despair of frailty, and the loneliness of aging and dying alone” (Georgetown University, 2005, para.
62). One way or another it is imperative to our aging society that a health care system is developed under the principals of autonomy, beneficence, and justice that will not deliver care based on rationing and determination of ones’ worth, but based on the individual and their health needs that will facilitate optimal aging and peaceful dying. References American Medical Association. (1988). Ethical implications of age-based rationing of health care (I-88). Retrieved from http://www.
ama-assn. org/resources/doc/ethics/ceja_bi88. pdf Binstock, R. H. (2007, August). Our aging societies: ethical, moral, and policy challenges. Journal of Alzheimer’s Disease, 12, 3-9. Retrieved from http://web. ebscohost. com. ezp. waldenulibrary. org/ehost/pdfviewer/pdfviewer? sid=64fb29eb-cd59-49c6-8750-ad2528de0fba%40sessionmgr110&vid=13&hid=114 Georgetown University. (2005). Taking care: ethical caregiving of our aging society. Retrieved from http://bioethics. georgetown.
edu/pcbe/reports/taking_care/chapter1. html Institute of Medicine of the National Academies. (2008). Retooling for an aging America: building the health care workforce. Retrieved from http://www. fhca. org/members/workforce/retooling. pdf Kovner, PhD, A. R. , & Knickman, PhD, J. R. (2011). Jonas & Kovner’s Health Care Delivery in the United States (10th ed. , pp. 1-404). New York: Springer Publishing Company. Maddox, P. J. (1998, December). Administrative ethics and the allocation of scarce resources.
The Online Journal of Issues in Nursing, 3(3). Retrieved from http://www. nursingworld. org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol31998/No3Dec1998/ScarceResources. html Teutsch, S. , & Rechel, B. (2012). Ethics of resource allocation and rationing medical care in a time of fiscal restraint _ US and Europe. Public Health Reviews, 34(1), 10. Retrieved from http://www. publichealthreviews. eu/upload/pdf_files/11/00_Teutsch. pdf