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Limiting Medical Care for the Elderly

The prolongation of life is ultimately impossible, but in the end, should it be the ultimate goal? Medical advances and technology can keep people alive longer, but it doesn’t necessarily give them a quality of life. Sometimes it prolongs suffering. The reason the elderly use such a large amount of medical resources is obvious, they are likely to have more health problems and need more care. Health care costs are rising dramatically, especially in a person’s last year of life. There is a solution to this issue; costs can be reduced by considering futility as criteria and promoting the use of advance directives.

Twenty eight percent of all Medicare spending is used on caring for people in the last year of their life and twelve percent is spent on the final two months (Fischbeck). It is predicted that the cost of Medicare will go from $427 billion in 2007 to $844 billion in 2117 (Callahan). This presents a significant problem for our government. As baby boomers age, the dependency ratios will change from about four working people per retired person paying into Medicare, to two and a half (Callahan). To keep the Medicare benefits at the level they are now, it would require a significantly large tax increase that families would not be able to handle (Callahan). Is it fair for the younger generation to bear the cost for the older generation? So, how do we deal with this? What is the right thing to do? A starting point to the resolution of this issue would be to look at medical futility in the treatment of the elderly and the ethics surrounding it.

Medical futility is defined as when medical interventions would not offer the patient any significant benefit. There are two types of medical futility: Quantitative and Qualitative (Jecker). Quantitative futility is when the medical intervention most likely will not benefit the patient (Jecker). The direction of care is looking at evidence-based data to support that the outcome is futile. An example would be in a study done by Dr Rubenfeld and Dr Crawford in 1996. Not one out of 398 patients who had a bone marrow transplant on a mechanical ventilator who developed hepatic failure, renal failure, hemodynamic failure, and lung injury survived. They concluded that an accurate prediction of death could be made in the first four days with patients meeting these criteria (Rubenfeld). The problem with this is that in treatment for the elderly, there is no defined consensus as to the statistical evidence for treatment to be considered futile (Poncy).

Qualitative futility is when the intervention will produce an outcome of poor quality of life (Jecker). An example would be when a ninety five year old man, who was very active in the community, falls, hitting his head, resulting in a very large subdural bleed of his brain, pushing his brain to one side. Comatose, with a dilated pupil, he shows signs of brain herniation, which indicates impeding death. If surgery is done to evacuate the hematoma, he may live, but his quality of life would be very poor. He may be vegetative and unable to return to an active life.

The common sense notion of futility is the most logical for containing exorbitant healthcare costs. This is futility as a valued choice. There is a time for all of us when death or disability should come naturally and life should not be extended by medical interventions. This would require society to realize that aging is not a disease, but a part of human life.

There are often situations in healthcare where treatment is given that only extends a persons life but does not return them to a quality of life. The following is an example of inappropriate care without the consideration of futility. An unfortunate eighty three year old man was admitted to the intensive care unit from a nursing home with the diagnosis of severe dehydration and possible pneumonia. This patient had severe Alzheiemers Disease; he was bedridden, nonverbal, blind, stiff and curled up with contractures of all his extremities. He had six non-healing open sores on his feet, head, elbows and coccyx and a sodium blood level of 175, which indicated he had probably not eaten or had enough fluid for the last month. The only family this man had was his elderly wife who rarely saw him in the nursing home because she didn’t have transportation. She was his proxy or decision maker and wanted him to be aggressively treated and resuscitated if he were to stop breathing because she stated, “I believe in miracles”. The aggressive treatment would require him to be intubated on a ventilator, treated with fluids and antibiotics. He would also require surgery for a feeding tube. Is it right to aggressively treat this eighty three year old with a very poor quality of life because the wife believes in miracles? This is morally and ethically inappropriate treatment.

Ethical care refers to a guideline for determining what is morally right and wrong. Conflict comes up when trying to determine the “right” thing to do for the patient due to personal thoughts, feelings, beliefs and evidence-based data (Poncy). Principles used to guide difficult decision in medicine include autonomy, benefiance, nonmaleficence, and justice (Poncy).

The first of these principles to address is autonomy which is the most desired principle because it allows a person to make his own decisions. Healthcare providers should be held accountable for communication with patients and their proxies, to encourage patients to declare an acceptance of natural death especially when treatment will not improve the quality of life or will just prolong pain and suffering (Poncy). This declaration should be in the form of advanced directives or advanced care planning. Advance directives are legal documents that allow a person to convey their decisions about end of life care ahead of time (Poncy). They provide a way for a person to communicate his wishes to family, friends and health care professionals, and to avoid confusion later on. This allows dignity for the person to make their own decisions about how they conclude their life.

The second principle is benfiance, which is defined as doing what is good. To guide difficult decisions one has to do what is good. Words that come to mind to describe doing good would be using kindness, compassion, empathy, sympathy, consideration, integrity, honesty and truthfulness. Good is to practice what is right and do right for yourself, your family and society, even against opposition.

Nonmaleficence is the third principle and it means to do no harm. Different religions support nonmaleficence with the same meaning but different language. Eighty percent of people in the world follow a religion that says doing anything hurtful to others is wrong (Uotinen) •	Buddhism’s Golden Rule “Hurt not others in ways that you yourself would find hurtful.” Udana-Varga 5,1. •	Hinduism’s Golden Rule “One should never do that to another which one regards as injurious to one’s own self.” Anusana Parva, Section CXIII, verse 8. •	Islam’s Golden Rule “Hurt no one so that no one may hurt you.” Muhammad, The Farewell Sermon. •	Confucianism’s Golden Rule “Never impose on others what you would not choose for yourself.” Confucius, Analects XV.24. •	Judaism’s Golden Rule “What is hateful to you, do not do to your fellowman.” Talmud, Shabbat 3id. •	Christianity’s Golden Rule “Do unto others as you would have others do unto you.” Mathew 7:12.

The final principle to consider is justice. It refers to doing what is best, ideal and moral for the entire community (Poncy). Using resources to prolong life with medical interventions for the elderly may produce a poorer quality of life and may not be what’s best for the entire community (Poncy). Perhaps what is best for the entire community is approaching the ethical issue with intensive caring.

Our responsibility in treating the elderly should actualize the ethic of caring. This supports allowing the elderly to maintain control of their decisions, allow them to have privacy, intimacy and dignity. Relieve suffering by alleviating their pain with medicine in a manner that won’t make them delirious, but will provide comfort. Provide nursing measures of caring, listening, providing a calm, comfortable environment and fostering memories of loved ones. Meet spiritual needs by providing psychological and spiritual counseling. This is ethically intensive caring and should be the healthcare team’s direction in providing care for the elderly; not providing medical interventions that prolongs life, yet may worsen the quality of that life. There are several arguments against limiting the medical treatment in the elderly. Some may argue against this as being unethical due to their religion or culture. Physicians practice with the fear of being sued by families that don’t agree in not aggressively treating their family member. Still others are against counseling the elderly regarding the acceptance of natural death because they believe that all human life is sacred and equally deserving of protection (Kilner). By not advocating life extending treatment, it denies patients of life itself. From this opposing standpoint it may be believed it can create an unequal respect towards the elderly, devaluing their lives and catering to a youth oriented culture (Smith). The real question is how to optimize the appropriateness of treatment and include ethical caring in value based healthcare to reduce healthcare costs in out country.

In conclusion, the solution to skyrocketing costs in Medicare spending is not actually limiting healthcare for the elderly but to optimize the appropriateness of treatment. The healthcare team must consider futility in individual cases where medical intervention is just prolonging life but not a quality life. Law must require physicians to ask patients about their advance directives and to encourage patients and families to declare an acceptance of natural death, especially when treatment will not improve the quality of life or prolong pain and suffering.

Works Cited Callahan, Daniel PhD and Kenneth Prager M D. "Medical Care for the Elderly: Should Limits Be Set?" Virtual Mentor (2008): 404-410. Fischbeck, Paul. "U.S. Healthcare an Industry in Transition." 27 April 2011. www.ficpa.org/Content/Files/Docs/CPE/CourseManuals. Document. 12 April 2012. Jecker, Nancy S. Ph.D. "Futility: Ethical Topic in Medicine." 11 April 2008. http://depts.washington.edu/bioethx/topics/futil.html. Document. 6 April 2012. Kilner, John. Who Lives? Who Dies?: Ethical Criteria in Patient Selection. New Haven: Yale University Press, 1990. Book. Poncy, M. "Program and abstracts of the National Conference of Gerontological Nurse Practitioners 25th	 Annual Meeting." 2007. Meddscapes Nurses @ Merdscape. LLC. 6 April 2012. . Rubenfeld, John M. Luce and Gordon D. "Can Health Care Costs Be Reduced by Limiting Intensive Care at 	the End of Life?" American Journal of Respiratory and Critical Care Medicine (2002): 750-754. Smith, George P. "The Elderly and Health Care Rationing." 22 May 2002. http://law.unh.edu/assets/pdf/pierce-law-review-vol07-no2-smith.pdf. Document. 6 April 2012. "Understanding Health Care Decisions." n.d. http://www.nia.nih.gov/health/publication/end-life- helping-comfor-and-care/understanding-health-care=decisions. 6 April 2012. Uotinen, Vic. "Applications of and Approaches to Ethics in All Aspects of Life." 8 November 2010. rpsd.ans.org/ethicsLIFE.pdf. Power Point. 6 April 2012.