Limiting Medical Care for the Elderly

Healthcare costs are rising dramatically especially in a person's last year of life. Solutions to cut dramatic rises in Medicare spending on the elderly and decreasing the burden we leave for the future generation are; using futility as criteria in limiting inappropriate care, promoting the use of advance directives and spending healthcare money wiser by the development of value based healthcare. Nurses Announcements Archive Article

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, promoting the use of advance directives and spending healthcare money wiser by developing a value based healthcare system.

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." orificeana 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 an attempt to redefine healthcare and spend healthcare money wisely, there is a shift in our country to change to value based healthcare delivery which focuses on containing costs by improving patient outcomes (Porter). Achieving and maintaining good health is less costly than dealing with poor health. Comprehensive outcomes need to be measured to know what improves the degree of health or recovery and what doesn't (Porter). This would tie into creating the statistical evidence to support when treatment is futile. We need to measure true health outcomes and reorganize care delivery. Our current system rewards those who bill for more services, not those who deliver the most value (Porter).

Rulon Stacey, Ph.D., FACHE, is the CEO of the University of Colorado Health System, and in an interview, talked about Accountable Care Organizations (ACOs) and how they tie reimbursements to quality measures and reduce total cost of care. Reimbursement is done based on bundling payments to cover the entire progression of care for a medical condition, including providers and services (Stacey). An ACO agrees to be accountable for the quality, cost and medical care of Medicare patients (Stacey). They do this by physician alignment and engagement, physician collaboration and best practice sharing. They develop better performance measures that support improvement and show that savings are achieved through that improvement (Stacey). Rulon stated "We are responsible for delivering quality outcomes and high levels of service at a reasonable cost." "We are responsible for learning, growing and changing." He also talked about the LEAN Process to increase quality and system savings. The LEAN Process is a rapid improvement event using hospital leadership in the teams to identify the value, and then eliminate steps that do not create value. Waste steps are removed and the quality improvement will reduce overall cost.

In conclusion, the solution to skyrocketing costs in Medicare spending is not actually limiting healthcare for the elderly, but to redefine how we spend Medicare's dollars 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 directive and to encourage patients and families to declare an acceptance of natural death. Especially, when treatment will not improve the quality of life; or may prolong pain and suffering. And finally, we must spend healthcare money wiser by developing value based healthcare systems which utilizes quality improvement, bundling of reimbursement payments and limit wastes in the containment of costs. We need to move towards a national healthcare strategy centered on value as well as intensive caring.

Refrences

Callahan, Daniel PhD and Kenneth Prager M D. "Medical Care for the Elderly: Should Limits Be Set?"

Fischbeck, Paul. "U.S. Healthcare an Industry in Transition."

Jecker, Nancy S. Ph.D. "Futility: Ethical Topic in Medicine."

Kilner, John. Who Lives? Who Dies?: Ethical Criteria in Patient Selection. New Haven: Yale University

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."

Stacey, Rulon Ph.D., FACHE. CEOof University of Colorado Health Marjory Schomberger.

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eschom04

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Specializes in Gerontology, Med surg, Home Health.

So let's say you're 25. You get drunk at a party, try to drive yourself home, and crash your car resulting in multiple life threatening injuries. You need to be intubated, ventilated, and placed in an ICU in a coma for months. Why should we spend money to keep YOU alive?? You chose your behavior. YOU put yourself (and others on the road) at risk. A baby born at 24 weeks....we spend millions on that person to attempt to keep them alive when chances are the outcome will be poor. Is that worth it?

We each need to decide for ourselves what constitues quality of life.

I'm 57 and in good health. My advances directives are in place and my health care proxy knows what they are and will follow them if I'm not in a position to speak for myself. I'VE decided...not you...not the government....not a group of strangers. It's MY life, MY wishes, and MY idea of what I consider quality of life for myself.

We should not make these decisions solely based on someone's age. YOU might think life is no longer enjoyable or worth living because you're 80 or 85 or 90, but I know many many 80 and 85 and 90 year old people who would vehemently disagree.

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I have seen many an ICU pt kept alive who I am quite sure would have preferred to be let go with dignity, had they been able to speak for themselves. Yes, they would have benefited from making their own directives, but I think that there are cases where having some basic guidelines in place for limiting the level of care would be appropriate. Every case is individual. Some 90 yr olds have a wonderful quality of life and can regain a large portion of that again. Some 50 yr olds have horrible quality of life. There are no hard and fast rules.

I think the example of the 25 yr old and the premature baby are seperate issues, but I would personally like to see some limits in place regarding premature children.

These are just my opinions. :specs:

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Specializes in Neuro ICU, Telemetry, Orthopedics.

Locked-in man 'condemned to suffer' - Yahoo! News UK

The above link is an interesting article about a UK man with locked-in syndrome secondary to a stroke. There comes a point where stopping treatment becomes the kindest action to take before the patient has to suffer like this for 7 years.

I work in a neuro ICU and see this all the time. Too often the proxy, family, or significant other will not honor the patient's wishes, even when there is an advanced directive, because they let their emotions rule and are guided more by the inability to let go. Doctors are unlikely to explain the difference between keeping someone alive and being able to restore a QUALITY of life, big difference; Most physicians today make decisions and lay out treatment options based on avoiding malpractice, which also adds to the high cost of health care. Just because we have the technology to keep someone alive, doesn't mean that we should.

Advanced directives are meaningless unless there is a change in how doctors lay out options and a legal enforcement of the patient's wishes.

It is sad how many patients, regardless of age, are denied a dignified death.

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Ethical issues are inherent to the decisions of prolongation of life, or withdrawing of life-support measures. Everyone has their own understanding of quality of life, and ultimately “hope” is the last thing to go.

What we can realistically do is to spread the word on availability of choice. I am not sure about other states, but both POLST and ACHD are recognized in Los Angeles and gaining more popularity amongst the clients. It might take some time, but eventually everyone should have an AHCD signed and notarized. This will eliminate multiple ethical situations as posed in OP article.

Advance Health Care Directive: What's Important to You | State of California - Department of Justice - Kamala D. Harris Attorney General

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Specializes in Cardio-Pulmonary; Med-Surg; Private Duty.

There are things worse than death... being kept "alive" unnecessarily is one of them, for me.

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Specializes in PICU, NICU, L&D, Public Health, Hospice.
So let's say you're 25. You get drunk at a party, try to drive yourself home, and crash your car resulting in multiple life threatening injuries. You need to be intubated, ventilated, and placed in an ICU in a coma for months. Why should we spend money to keep YOU alive?? You chose your behavior. YOU put yourself (and others on the road) at risk. A baby born at 24 weeks....we spend millions on that person to attempt to keep them alive when chances are the outcome will be poor. Is that worth it?

We each need to decide for ourselves what constitues quality of life.

I'm 57 and in good health. My advances directives are in place and my health care proxy knows what they are and will follow them if I'm not in a position to speak for myself. I'VE decided...not you...not the government....not a group of strangers. It's MY life, MY wishes, and MY idea of what I consider quality of life for myself.

We should not make these decisions solely based on someone's age. YOU might think life is no longer enjoyable or worth living because you're 80 or 85 or 90, but I know many many 80 and 85 and 90 year old people who would vehemently disagree.

If I am not mistaken we were legislated and mandated to care for those early term babies sometime back in the Reagan administration.

I would think that we (as a society) would attempt to care for that young drunk MVA victim simply because we are a civilized and wealthy country that values it's citizens.

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Specializes in kids.

And years ago, when the idea of a physician being reimbursed to have these quality of life discussions in a non urgent setting, was raised, they were immediately called death panels. Where better to have the conversation? When momma is 87 and has paralysis, cannot speak and needs a g-tube?? Or within the context of a regular office visit , where records can be reviewed and life us not hanging in the balance?

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Specializes in Dialysis.

I'd be happy if we returned to dialysis as bridge to transplantation. But that would deprive the nursing home patient with dementia the right to spend 3 hours with me in four point restraints.

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Specializes in Patient Safety Advocate; HAI Prevention.

I agree that this is a decision that each person should make for themselves. However, I have never met anyone who says they want to be kept alive with a vent, meds, tube feedings, and other interventions, when there is no hope for regaining any quality of life. Nobody! End of life care can be torture, and very expensive torture at that. Medicare will pay for all of that, even if it is futile. They also pay for other crap that is absolutely useless to the elderly, like cholesterol testing, screening mammograms, any variety of ultrasounds, crazy expensive cardiac tests, yearly pap tests etc. I know because they have paid for that for my 90 year old mother, who could benefit much more from increased payments for her needed medications and for her assisted living care. We need to start payinig for what matters to patients, not what is most expensive and unnecessary at end of life.

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I found this article thought provoking and long over due. A large percentage of the elderly when given the option would choose not to live if the would be brain dead, not know who they are, or loose their quality of life. My father filled out a living will and specifically stated he wanted to maintain his quality of life and did not want to spend the remainder of his life in a nursing home. Though the doctors didn't initially want to follow my fathers living will. My sister and I convinced them that this was our father's wishes and we are following them. This is an excellent article addressing a very difficult for society to deal with. However, the most significant obstacle is to have all elderly complete a living will and ensure they understand what will happen to them in the process to save their lives i.e. (CPR, vents, possible loss of quality of life...).

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Specializes in Critical care.
And years ago, when the idea of a physician being reimbursed to have these quality of life discussions in a non urgent setting, was raised, they were immediately called death panels. Where better to have the conversation? When momma is 87 and has paralysis, cannot speak and needs a g-tube?? Or within the context of a regular offices visit , where records can be reviewed and life us not hanging in the balance?

We went through something similar over here in the U.K. a couple of years ago. It was suggested that general practitioners should have discussions with some of their more elderly patients as to what they felt about being resuscitated should their heart stop with a view to having a dnar that could be shared, should they not have the capacity to make their wishes known. Of course, some of the more shrill sections of the U.K. press (who think a dnar is "playing God") were up in arms over this. Of course, for the unindoctrinated, cpr is like what you see on television, a few compressions, a zap from the defib and they're back in the room. Whereas, I'm sure we can all agree, the reality is a lot more brutal and undignified.

I agree with the first rep,y to the article on the topic being discussed in the OP (I've not read the OP in its entirety, I'm about to leave for a nightshift, but I'll try to read it in full when I have the time) but there shouldn't be an arbitrary set age for deciding on limitations of care, it should be done on individually, based on someone's QOL, the likelihood treatment would be successful and their own wishes.

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