Who cares for the elderly?
Seniors suffer in an age of limited health care
resources
By Lisa Schmidt
When Shakespeare said, "There is small choice in rotten apples,"
he could well have been prophesying some of the difficult decisions about
who gets treatment in health care facilities and programs in the modern
era.
Indeed, allocating health care resources when these resources are limited,
inadequate, costly or inaccessible often comes down to making choices
between what may appear to be the medical system's bruised fruits: poor
service or no service.
Compound this with the prevailing stigma against the frail, the chronically
ill and those with mental health or addiction issues and you have what
Dr Michael Gordon, vice-president of medical services at the Baycrest
Centre for Geriatric Care in Toronto, describes as "a world where
demented, old people have no value and consequently may get no or inadequate
treatment."
Resource allocation, the decision-making process that distributes health
care programs and services, is rapidly emerging as the principle issue
for health care administrators and governments everywhere, as costs escalate
and funding for programs that affect the determinants of health, such
as housing and employment, is lacking.
And how we care for the sick and frail will become a more pressing concern
as our population ages and develops health care needs beyond what we are
currently capable of handling. Already, in many jurisdictions, there is
a shortage of care options for older persons no longer able to care for
themselves. Some health care providers in the field of aging simply say:
if you happen to be old and broke, you may literally be left out in the
cold.
As the clinical co-ordinator for a program at the Centre for Addiction
and Mental Health called OPUS 55 (OPUS being Older Persons, Unique Solutions)
Margaret Flower agrees that the lack of services and programs for older
adults is a huge problem. The program addresses the specific needs of
people age 55 and over with substance use problems and age-related issues.
Flower says there is no shortage of demand for services for this group.
"It is completely unacceptable that as soon as a person gets old,
they somehow no longer qualify for humane and compassionate treatment."
She cites the example of an older man who began drinking after the death
of his wife eight years ago. He was in good health even though he wore
a pacemaker. When it came time to replace the aging pacemaker, his doctor
told him that he was no longer a good candidate due to his drinking, and
was refused the replacement, even though that meant he would likely die
when the old pacemaker broke down. Says Flower: "He said to me: 'I've
been given a death sentence because I am old and I drink.' It was very
difficult for me to watch him go through this: as a health care provider,
I was appalled at what seemed to be a highly unethical decision based
on financial, not ethical, responsibilities."
That these questions are profoundly ethical in nature is clear to those
who advocate on behalf of older persons, particularly those with mental
health and addiction problems. Gordon says that there has been a tendency
in health care to make ethical decisions from a purely utilitarian perspective.
"Health care providers and administrators have a hard time using
an ethical framework for decision-making, so they become 'practical,'"
he says. "If this became a prevailing attitude, it could lead to
a situation, for instance, where in a palliative care situation, a patient
might be allowed to die more quickly to, in a 'practical' way, free up
beds for others who are also dying."
Janet Chéné, director of long-term care at the Mount Hope
Centre for Long Term Care in London, Ontario, has watched the trend to
deinstitutionalize psychiatric clients into the community -- including
older adults who require intensive monitoring. She notes that some people
fare better than others and that this often depends on what happens to
be available when they need it.
"Some older adults who are discharged from psychiatric institutions
to nursing homes actually do better in these environments," says
Chéné. "There is a normalization of their routines,
and there are often more social and recreational supports than where they
came from."
But on the negative side, people are sometimes denied admission because
their needs are so high. "A nurse may have to spend an hour in a
hospital isolation unit getting an agitated client to take his medication
in some cases, but we don't have the resources here to do that,"
says Chéné.
So what happens to these clients? Some end up right back at the psychiatric
facility, says Chéné of clients who are difficult to treat,
particularly ones with aggressive tendencies. But she notes that there
are some hints that, at least in Ontario, people may soon have a place
to go; the Royal Ottawa Hospital has received approval to build long-term
beds for older people with psychiatric problems.
Reflecting on the state of care for older adults, Chéné
adds: "The combination of being old and having a psychiatric illness
places these clients in a very vulnerable position. We need to continue
to work to convince those who control the resources that these people
are just as important, deserving and valuable as anyone else."
Fast Facts
- By 2021, people 65 years and older will account for 18 per cent of
the Canadian population, or 6.7 million people.
- Recent studies have shown that approximately 80 per cent of nursing
home residents have at least one psychiatric disorder.
- Canada's health care spending is higher than ever before. In total,
we spent $102.5 billion to maintain or improve the health of Canadians
(about $3,300 per person). Most of this is spent on hospitals (32%)
and medications (15%).
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