Martha Armstrong, Professor, Social Work & Gerontology, Ohio Dominican College

Allison Batchelor, M.D., Medical Director Senior Services, John J. Gerlach Center for Senior Health, Grant/Riverside Methodist Hospitals

Location:

Westminster-Thurber Community, 717 Neil Ave., Columbus, Ohio 43215

Ohio Presbyterian Retirement Services (OPRS) hosted the June Conversation at Westminster-Thurber Community. OPRS is Ohio's oldest and largest nonprofit provider of continuing care retirement communities since 1922. More than 2,400 residents are currently being served in eight communities across the state. Information about the Westminster-Thurber location and a tour of the facilities was provided by Jerry E. Stewart, Chaplain/Director of Pastoral Care. Nearly 400 persons live at Westminster-Thurber.

DR. ARMSTRONG'S REMARKS
The central issue of the public policy debate regarding the nature and limits of our obligations to older adults concerns criteria that should be used in making difficult choices in the distribution of scarce resources. Some authors focus this debate on an equitable distribution between young and old. Others focus on the haves and have-nots. Others respond that it is unfair to blame the old for the larger problems that society faces.

During the decades of the sixties and seventies, older adults in the U.S. society were generally viewed according to a form of compassionate ageism as a homogeneous group of frail, impoverished individuals. Marked gains were made, perhaps best illustrated by the fact that approximately 1.7 million elders were pulled out of poverty during the three years following the 1972 amendments to the Social Security Act.

Beginning in the early 1980s, as sectors of U.S. society gained heightened consciousness of the limited nature of resources, another form of stereotyping developed which views older adults as an affluent, selfish group which is taking more than its fair share of limited resources at the expense of other needy segments of society, particularly children. While older adults as a group have achieved economic parity with other age groups, large pockets of poverty remain among older adults. The heterogeneity of the aged population makes it difficult to predict needs on age alone.

Demographic forecasts must also be taken into consideration. At present it is anticipated that around the year 2050 older adults will comprise approximately 22 percent of the U.S. population. Deeply held societal values insist on family support of young and old members . . . The question of society's ability to support various age groups at appropriate levels is a complex one. Persuasive arguments indicate that scenarios that severely tax or otherwise curtail entitlements for older adults cannot free up sufficient resources to adequately address the needs of other segments of society.

In surveying alternative approaches to the just allocation of scarce resources, the classic utilitarian position recommends dividing limited resources equally among society's members. Finding this unsatisfactory for addressing the needs of different groups in society, we might attempt to achieve a "fair" allocation in terms of the outcomes achievable in using these resources.

The concept of reciprocity, founded in the notion of deserved benefits, forms the traditional basis for intergenerational support in our society. In exploring reciprocity from an economic view, it becomes clear that this binds each generation both to the one that preceded it and to future generations.

An alternative perspective based in the concept of distributive justice is perhaps best reflected in the work of the philosopher John Rawls who argues that in distributing limited resources, preference is to be given to providing at minimum an acceptable quality of life for the most vulnerable members of the society. Such a social justice position does not "play well" in many sectors of U.S. society in part due to our cultural affinity for fair play as represented by the concepts of contracting and the notion of entitlement based on merits.

. . . Given the great diversity within U.S. society, it is difficult to imagine a consensus arising concerning the choice of one of the competing ethical perspectives by which to establish criteria for distributing scarce resources among generations. In struggling with concrete policy decisions, it would prove fruitful to mirror alternatives against the various ethical standards available for our consideration. And in this process, we need always to ask whether policies fairly account for individual and family ethical and cultural interests, or do they ignore individual and family interests in favor of community or provider financial interests?

One set of recommendations for framing and analyzing issues associated with the aging of America has been presented by Eric Kingson and coauthors in the publication, Moody, Harry R. Aging, Concepts and Controversies. Thousand Oaks, California, 1994.

• The aging society is both a success and a challenge.
• The elderly population is greatly diversified.
• The relationship between individuals and generations is characterized essentially by interdependence and reciprocity.
• All generations have a common stake in social policies and intergenerational transfers that meet needs throughout the life course.
• The nation's future can be changed and shaped by choices made today.

Five fundamental principles for humane, cost-effective social policy have been proposed by H.E. Moody, Brookdale Center on Aging of Hunter College, New York.

• First, limits should be acknowledged when developing biomedical technologies for life prolongation and in basic research on lifespan extension.
• Second, we need a fairer distribution of burdens, not just benefits: we need to acknowledge the "two worlds of aging" and readjust our ideology accordingly.
• Third, the emphasis should be on productivity and social contributions, rather than on redistribution according to the style of interest-group liberalism.
• Fourth, an affirmative family policy should be linked to aging, which would include support for family care-givers and filial responsibility.
• Fifth, there needs to be a principle of universality and comming citizenship, which would imply both a "citizen's wage" and a willingness to sacrifice for the common good and future generations.

DR. BATCHELOR'S REMARKS
Many of the ethical issues in caring for older people revolve around terminal or end-of-life care. My focus will be on the ethical principle of autonomy and decision-making in end-of-life care.

Autonomy is a term derived from the Greek words autos or self and nomos or law, so it literally means self-rule. In U.S. society, the concept of personal autonomy plus individual self-determination and decision-making is primary to our culture. The guarding of individual rights is primary to U.S. thought. However, autonomous behavior has the constraint of not causing harm to others. Likewise, a person who is not capable of self-governance is not able to act with autonomy. Examples would be a person with mental impairment due to Alzheimer's disease, or a stroke victim who lies in a coma. These are persons who lack the ability to make decisions for their own care. Thus a geriatrician must work to ensure the protection of autonomy through Advance Directives in preparation for future decision-making. (Geriatrics is the medical field concerned with the caring for older patients.)

Advance Directives are documents that allow an individual to give directions about his/her future care. There are two main types:

1. Living Will
2. Durable Power of Attorney

The second important document is a Durable Power of Attorney (DPOA). This is a written document appointing someone to be a proxy or surrogate to make decisions on behalf of a person in the event he/she becomes unable to do so independently. It is called durable because the person serving as power of attorney maintains the authority to manage a patient's affairs after that patient is no longer capable of doing so. A regular power of attorney loses its power when its grantor is no longer capable of directing the surrogate. Ohio has two types of durable power of attorney. A plain DPOA appoints a surrogate to handle all business, financial, and legal matters. A separate DPOA for health care appoints a surrogate to make health care decisions. In some states, one DPOA document can provide for both business and health care. Having both is the best approach to Advance Directives.

. . . What about the responsibility of the surrogate? Surrogates must remember they are the conduit through which the patient's wishes are shared with the physician. Surrogates do not impose their wishes for the patient care. As a physician speaking with surrogates, I always carefully define this as follows"I am not asking you what you want for your mother's care, I am asking you what your mother would want if she could tell me herself. You know her infinitely better than I do, so I am counting on you to tell me what her decision would be based on your experience with her and your knowledge of her wishes." This clarifies their surrogate role. What happens when patients are no longer able to speak for themselves but there are no Advance Directives? Increasingly, physicians, hospitals, and nursing homes are requiring family members to have formal DPOA appointments that give them legal authority to speak for the patient. Being "next-of-kin" no longer is sufficient in many circumstances. If no such advance documents exist, and the patient is mentally incapable of decision-making, then a court proceeding to appoint a legal guardianship may be necessary. The guardian may be a family member, friend, lawyer, or state-appointed individual who either makes decisions for business and/or health care issues for the individual patient.

This brings up the term incompetence, a legal term stating that a person can not make decisions for himself or herself. In determining whether a person has sufficient decisional capacity to be deemed competent, the following basic questions must be asked:

1. Can the person make and express personal preferences?
2. Can the person give reasons for the alternative selected?
3. Are these reasons rational and do they logically support the choice made?
4. Can the person understand the risks and benefits of the available alternatives?
5. Does the person understand the implications of the decision at hand?

What are some of these complex medical treatment decisions that patients and their surrogates face today? Medical technology has revolutionized geriatric care. We now have:

1. Cardiopulmonary resuscitation (CPR) that is used whan a person's heart or breathing stops.
2. "Life support machines" such as respirators (breathing machines).
3. Artificial kidney machines for dialysis.
4. Feedings tubes t can feed an unconscious patient.
5. Intravenous tubing that can supply hydratant medications including antibiotics.
6. Complex surgeries such as open heart procedures, organ transplants, cancer opertions, and many other highly technical diagnostic tests, treatments and medications.

Clearly this raises many issues of communication associated with maximizing a person's chance to maintain autonomy despite decisional-incapacity. All sorts of medical care decisions must be made regarding life-supporting care. I must note, however, that, ethically and legally, withdrawal of life-sustaining medical therapy is viewed no differently than withholding the same treatment in the first place. Beginning a treatment does not preclude stopping it later. This enables time-limited trials of particular interventions with the understanding that they will be re-evaluated and may be withdrawn if goals are not being met.

As evidenced by my comments, the complexity of preserving autonomy of older persons within our medical system raises multiple ethical issues in the care of older persons, especially in end-of-life care. To assist medical practitioners with these issues, the Ethics Committee of the American Geriatrics Society (AGS) has developed a position statement that includes nine specific points and the rationale for each, and a list of references. (See Selected References.)

SOME QUESTIONS AND ANSWERS
Should a hospital be allowed to charge a patient for services he doesn't want?
Response: I do not know of any legal cases that have come forward on this topic. However, I believe the response of a hospital legal team would be: If the hospital did not have any way to know that the patient didn't want this service in other words, it wasn't documented, the hospital would not be at fault. If it were clearly documented, it could then be determined that the hospital would be at fault.

How can a hospital legally and ethically ask for instructions and then ignore them? Not long ago there was a case where the court ruled in favor of the hospital even though the patient did not want his resources used up by resuscitation, and wanted them left for his family.
Response: I would not have thought the court would have ruled that way if the instructions were clear. I have not heard of that case.

Comment: Procedures for resuscitation do not always net a positive outcome only about 15% live through this process. Only about 0.5% of those who survive the process make it out of the hospital. If we started honoring people's wishes, we could save approx. 20% of medical care expenses.

How does the means test for Medicare fit into your discussion of justice?
Response: It is inevitable as a practical matter that there will be a chipping away at what has been needed for entitlement for older persons when they are looked at as an entire group of people. Clearly there are large pockets of persons who are truly impoverished and are older persons. If we do the means testing, we could be doing a number of things depending upon where it is pitched. This means that it depends upon:

1. Who writes the regulation?
2. What are we saying here?
3. What are we doing to the persons who have reached middle class economically and are hanging on financially with their fingernails?

SELECTED REFERENCES

The American Geriatrics Society. Ethics Committee. Position Statement: Making Treatment Decisions for Incapacitated Elderly without Advance Directives. New York, 1995. 5p.

Callahan, Daniel. Setting Limits. New York: Simon & Schuster, 1987.

Daniels, Norman. Am I My Parents' Keeper? New York : Oxford University Press, 1988. Kingson, Eric R., et al. Ties That Bind: The Interdependence of Generations. Washington, D.C.: Seven Locks Press, 1986.

ABOUT THE PANELISTS

Martha Armstrong's Ph.D. was in social work with a concentration in public policy and was received from The Ohio State University. Prior to her current position as Professor of Social Work and Gerontology at Ohio Dominican College, she was associated with management programs for older adults.

Allison J. Bachelor received her undergraduate degree from Ohio Wesleyan College and her medical doctorate from the Medical College of Ohio at Toledo. She was a resident at Brown University/ Rhode Island Hospital; Senior House Officer for Geriatric Medicine at Radcliffe Infirmary, Oxford University; and a Fellow in Geriatric Medicine at the University of Connecticut Health Center.

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