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Older Persons' Rights for Self - Determination in End-of-Life Decision s Abroad

Sooyoun Han, PhD, MSW, Founder Care Rights (Republic of Korea). Older Persons' Rights for Self - Determination in End-of-Life Decision s Abroad. Problem Statements…………………….…………………………... 3 Increase of Ageing Migration in South Korea…………………...... . . 5

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Older Persons' Rights for Self - Determination in End-of-Life Decision s Abroad

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  1. Sooyoun Han, PhD, MSW, Founder Care Rights (Republic of Korea) Older Persons' Rights for Self-Determination in End-of-Life DecisionsAbroad

  2. Problem Statements…………………….…………………………...3 Increase of Ageing Migration in South Korea…………………........5 Lack of Awareness and Cultural Incompetency Regarding EOL Decisions in South Korea……………………………..……………..6 Identified Problems for Foreign Travelers and Foreign Nationality Residents…………………………………………………………….9 Care Rights Program Goals, Activities & Outcome………………..12 Table of Contents 2

  3. The phenomenon of rapid global ageing has led to challenges related to human well-being. The older population is itself ageing. Globally, the share of older personsaged 80 years or over (the“oldest old”) within the older population was 14 percent in 2013 and is projected to reach 19 percent in 2050. If this projection is realized, there will be 392 million persons aged 80 years or over by 2050 –morethan three times the present number (U.N. Department of Economic and Social Affairs, 2013) The number of international migrants worldwide reached 232 million, up from 154 million in 1990. The global population of international migrants is growing at a rate of about 1.6 percent per year (U.N. DESA, 2013). Problem Statements 3

  4. Figure. 1. International Migration, 2013 4

  5. Figure 2. Age distribution of international Migrants, 2013 5

  6. Figure 3. Eight-Point Agenda for Making Migration Work 6

  7. Numerous potential obstacles for foreigners in need of EOL care abroad are seen, including: Absence of EOL decision processing for foreigners Differences in cultural and healthcare legislation regarding patients’ autonomy between two countries Language barriers Such problems could lead to: Disparities in the decision-making process regarding EOL care Violation of human rights Elder abuse in crisis situations, including “stranded migrants” Unnecessary medical expenditures Problem Statements 7

  8. Return migrants: “persons returning to their country of citizenship after having been international migrants in another country and who are intending to stay in their home country for at least a year” (U.N. Division for collecting data on international migration, 1998). In 2011, 2,128 people reverse migrated to South Korea from the U.S. : the largest population of reverse migrators to South Korea overall. (Korean Ministry of Foreign Affairs, 2012). 95,234 American Nationals aged 60 years or older entered South Korea in 2011: 14,708 of them remained in the country three months or longer with registered foreigner status from the U.S. (Han, 2012). Increase of Ageing Migration in South Korea 8

  9. 1. Family Norms and Patients’ Autonomy on EOL Decisions in South Korea. Cultural ideas and expectations for family caregiving play a crucial role in the EOL decision process :Many Asian countries find such discussions taboo and against filial piety. Often, elders do not understand the concept of patient autonomy and EOL decisions are relegated to family caregivers (Haung, Hu, Chiu, & Chen, 2008; Kwon 2010). As a result, Korean healthcare staffs are not trained in EOL communication skills for EOL decision making processing(Han & Lee, 2013). Lack of Awareness and Cultural Incompetency Regarding EOL Decisions 9

  10. 2. Lack of Hospice Services and Social Services for EOL Decisions in South Korea. Lack of legal and social services raise the risk of misconduct and/or neglectance in EOL processes, leaving insufficient EOL decisions that could lead to elder abuse in the forms of neglect, inequality, and discrimination. Foreign travelers or residents are vulnerable to have possibly unwanted aggressive treatments, as opposed to pre-requested EOL decisions that are culturally-designed, pain-free and provided by comfortable hospice care. Lack of Awareness and Cultural Incompetency Regarding EOL Decisions 10

  11. 3. Healthcare Legislature and Patients’ Autonomy Regarding EOL Decisions in South Korea. Legislation such as the U.S.’s Patient Self-Determination Act (Pub. L. No. 101- 508,PSDA), which calls for Advance Directives for Health Care, but not yet enacted in South Korea. As of now, the South Korean Emergency Medical Service Act (EMSA) requires that hospitals and healthcare providers provide mandatory emergency medical services to all patients, contingent upon certain disparities. Lack of Awareness and Cultural Incompetency Regarding EOL Decisions 11

  12. 1. Conflicts Between Legal and Health Insurance Systems The Korean government founded the Emergency Service Fund (ESF) to reimburse unpaid expenses to medical service providers (Song, Kim & Lee, 2008). One fourth of this fund was paid for by foreign emergency patients. Most travel insurance plans have a max. coverage cap and do not always cover all options for life-sustaining treatments. Public insurance like Medicare does not cover medical costs abroad; others cover only partial medical costs. Identified Problems for Foreign Travelers and Foreign Nationality Residents 12

  13. Issues such as unwanted life-sustaining treatments for those with completed Advance Directives for Health Care may arise due to responsibility of expenses and national and international legal issues. Reasons for such problems include: Lack of clear and culturally-sensitive information Deficits in health care legislation Lack of legislation for self-determination of EOL decisionin some countries Cultural differences and language barriers Identified Problems for Foreign Travelers and Foreign Nationality Residents 1. Conflicts Between Legal and Health Insurance Systems (continued) 13

  14. 2. Violation of Human Rights Foreign travelers and/or residents are at a higher risk for misconduct and/or neglectance in EOL care left with insufficient EOL decisions that could form another type of elder abuse abroad. Foreign travelers and/or residents are easily deprived of rights to beinginformed about self-determination at EOL care in abroad. In South Korea’s current state, the rights of foreign travelers and/or residents who do not wish to receive aggressive life-sustaining treatments cannot be protected if unable to make EOL decisions at the time of service. Identified Problems for Foreign Travelers and Foreign Nationality Residents 14

  15. Program Goals Care Rights is working… To prevent neglect, abuse, and the violation of human rights of older persons in their EOL care in South Korea. To ensure human rights are met by allowing older adults who are foreign travellers or foreign national residents to make EOL decisions in advance with the benefits of cultural sensitivity and competent language services. 15

  16. Program Goals Care Rights is working… • To reduce misconduct in life-sustaining treatments caused • by a lack of health legislation, communication, and educational • materials about EOL care and the rights of foreign travellers and • foreign nationality residents. • To provide a psychoeducational intervention program to reduce • the tremendous emotional and psychological burdens of long- • distance family caregivers, as well as healthcare providers and • staffs. 16

  17. Care Rights’ Target Populations… Foreign travellers and foreign nationality residents in South Korea Long-distance family caregivers of foreign travellers and foreign nationality residents in South Korea Health care providers and staffswho provide emergency medical services to patients who are foreign travelers and/or foreign nationality residents Program Target Population 17

  18. Care Rights’ Activities… Provide a psycho-educational intervention program for older persons who are foreign travelers and/or foreign nationality residents and their caregivers about end-of-life care and rights in South Korea 2. Implement National Advance Directives for Health Care Form and provide them to foreign travelers and foreign nationality residents on a regular basis. 3. Educate healthcare workers and social workers about EOL decision processing, and publicly advocate the rights of elderly patients in their autonomyin EOL decisions. Program Activities 18

  19. Care Rights’ Activities… Develop brochures and materials about the rights to EOL decisions, National Advance Directives for Health Care Form, and cultural supports to ensure that foreign travelers and foreign nationality residents are aware of their rights and do make decisions regarding their EOL care Work collaboratively with the Korean Ministry of Foreign Affairs and NationalImmigration Service to provide such materials and services to foreign travelers and foreign nationality residents visiting South Korea. Program Activities 19

  20. Care Rights’ Outcome… Protect older foreign travelers and foreign nationality older residents’ rights to EOL decisions abroad, ensured by theMadrid International Plan of Action on Ageing, 2002. Improve older person’s dignity and autonomy in the process of dying. Lighten stress and burden of long-distance family caregivers, including those who are located abroad. Care Rights Program Outcome 20

  21. Care Rights’ Outcome… Reduce unnecessary medical expenses incurred by misconduct andneglect that go against the rights of foreign older travelersand foreignnationality older residents’ in their EOL decisions. Develop International Older Persons’ Human Rights Instruments for EOL decisions and well-dying processing, focused on one of the main areas of concern for the lack of special measures, mechanisms and services (The Second Assembly on Ageing, A/66/173, 2011). Program Outcome 21

  22. UNDP(2013). Population Prospects, 2012 Revision. U.N. Department of Economic and Social Affairs (2013). World Population Polices 2013. New York: U.N. U.N DESA. (2013). World Population Ageing 2013. New York: U.N. United Nations (1998). Statistics Division for collecting data on international migration. Korean Ministry of Foreign Affairs (2012) Diplomatic White Paper.www.mofa.go.kr/ENG/policy/whitepaper/index.jsp?menu=m_20_160 Han, S. B. (2012, 05 03) Rush of reverse migration due to expensive medical cost in abroad. Seoul Newspaper http://www.seoul.co.kr/news/newsView.php?id=20120503010010. Huang, C-H., Hu, W-Y., Chiu, T-Y., Chen, C-Y.(2008). The practicalities of Terminally Ill Patients Signing Their Own DNR Orders: A Study in Taiwan. Journal of Medical Ethics, 34(5). 336-340. Kwan, Iro & Bae, H.A. (2011). A Narrative Analysis of Ethical Issues Regarding End-of-Life. J of Korean Medicine & Ethic, 14(2). 157-170. Han, S. K. & Lee, H.J.(2013). A Discussion on Elderly Patients and their Family Caregivers’ Decision Making for Life Sustaining Treatments. GRI, 15(2). Song, K.M., Kim, Y. S., & Lee, Y. H. (2008). Legalistic Study of the SubrogationPayment in Emergency Medicine. The Korean Study of Law and Medicine, 9(2), 139-179. UN, Economic and Social Council (2012). Report of the UN High Commissioner for Human Rights. Substantive Session References 22

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