Progressive Meditations on the Essential Transformation of Geriatric Care

British Medical Journal

Editorial Reprint

Published February 2, 2004

The long-term care implosion has already begun in the United States.
 The unprecedented, prodigious global growth of the aging population
 demands attention and a radical response and reform from both policy
 makers and professionals on the front-lines of geriatric care.

In the United States, there is a prevailing perception that the
 influx of elderly will burden the health care system. Cost containment,
 tacitly and explicitly, is growing in support and popularity, and as a
 result, more elders cannot obtain medical and mental health care.
 Physicians are finding elderly difficult to treat because of their medical
 complexity, psychosocial issues and lack of funding from Medicare and
 Medicaid programs. A significant number of primary care physicians limit
 the number of new geriatric patients; this is more pronounced with rural
 elderly and Medicaid (low-income) recipients who have difficulty locating
 and accessing doctors. All the while, health care costs are exponentially
 increasing. Critics of the system emphasize that one-third of our medical
 spending on the elderly may be for needless or ineffective procedures.

Families of elders are still responsible for the costs of long-term
 care, and some projections state that approximately 80% of geriatric care
 comes from elders’ families and friends. The cost of these services
 exceeds $196 billion (Arno, Levine & Memmott, 1999), and yet, despite
 the abundance of psychological research that supports “aging-in-place” /
 family support services, legislators and policy makers continue to ignore
 this reality and the need for reform.

According to the Dept. of Health and Human Services, long- term care
 facilities in the United States continue to have too few personnel
 necessary to adequately meet the most basic needs and care standards. And
 despite the doubling of government reimbursement to these institutions,
 staffing did not increase. Rather, the resources were used to support
 profitable takeovers of smaller facilities(Center for Medicare Advocacy).

Medicare costs continue to escalate, and because Medicare does not
 cover the outrageously expensive tab of long- term, skilled nursing care,
 American elders are compelled to propel themselves into poverty by
 selling and manipulating assets so that Medicaid pays for these services.
 The euphemism for this sanctioned impoverishment is called “spending
 down.” I cannot begin to fathom the erosion of dignity and self-worth
 that occurs when the elder acknowledges that his/her hard earned assets
 have quickly dissipated in order to receive health care during the frail
 years of their life.

What about prescription coverage? Probably more that 60 % of
 geriatric patients in the United States have some form of medication
 insurance coverage. But the American Association of Retired Persons notes
 that more than half of drug costs are still paid by seniors alone with no
 reimbursement. The cost is more expensive for seniors than what hospitals
 and HMOs pay. Recently, several pharmaceutical companies offered
 assistance to seniors with well-intentioned prescription plans, but this
 is still not enough. Because of the inability to pay, many elders either
 discontinue the medicine or alter (reduce) the dosage without their
 physicians’ knowledge or authorization.

What can and should we, as professionals, do to change these
 injustices? This reminds me of a parable — a man stood in anguish before
 God screaming because of all the anguish and pain in the world. He cried
 out, “Look at the suffering and pain in your world! Why don’t you send
 help?” God responded, “I did send help…I sent you.”

We can become change agents by actively advocating and agitating for
 the following:

1) Support a holistically culturally-competent model of health care
 that includes the psychological, physical, nutritional, social and
 spiritual elements of care. Ongoing training that includes these elements
 for long-term care staff in the management and amelioration of the most
 common disorders of the aged is vital.

2) We must strenuously advocate for practices that emphasize the
 ethical treatment and care of the elderly. Health care professionals must
 apply the golden rule and platinum rule of ethics to caregiving.

3) We have to rigorously advocate for innovative training programs
 developed to foster competence in geriatric professional care. We must
 teach physicians, nurses and long-term care personnel to practice
 increased emotionally supportive care rather than the fatalistic,
 abandonment-oriented, sterile, depersonalizing care we often witness, hear
 and read about. Mandatory geriatric rotations that include a psycho-
 spirtitual and family-systems oriented emphasis are vital. We must train
 professionals to include family and caregivers in all phases of the doctor
 -patient relationship. Family members are indeed the secondary victims -
 the silent sufferers — of the elder’s disease process.

4) Palliative care must become an integral part of care. The term
 “dying with dignity” should be more than rhetoric, it should be practiced
 and breathed. A significant number of elders die with excruciating
 physical pain, and many die alone, with no connection to a present,
 caring, loving individual helping them to make the sacred exit.

5) Every effort should be made to support family caregiver programs
 ranging from respite care to in-home nursing care. This may result in
 increased quality and financially prudent outcomes for the elder, the
 family and the health care system as a whole.

6) We must further the research on brain plasticity and resilience
 and support psychosocial activity programs that strengthen mental capital
 and slow the progression of dementia-like syndromes.

7) It is imperative that we advocate and enforce a zero-tolerance
 policy on long-term care neglect and abuse of the most helpless of our
 society — institutionalized elders. Why are the elderly perceived to be
 so qualitatively different than children? Why does one lose his/her
 sacred humanness once they become wrinkled, gray and enfeebled? Arguably, if the atrocities and neglect that occur in long-term care facilities
 today would occur in a child day-care center or school, the public outcry,
 media exposure and legal/criminal consequences would be fierce and swift.
 I am certain that the institution would immediately be shut down and the
 perpetrators and management would be publicly brought to justice.

8) Finally, we must constantly become introspective and explore our
 attitudes and perceptions about the aging and dying process. Empathy and
 presence are vital ingredients.

Martin Luther King Jr. left us with a very appropriate quote that has
 immense relevance to the care of our elderly: “I have the audacity to
 believe that people everywhere can have three meals a day for their
 bodies, education and culture for their minds, and dignity, quality, and
 freedom for their spirits. I believe that what self-centered men have torn
 down, other-centered men can build up.”

Stanley M. Giannet, Ph.D.