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Healthcare Inequalities in the Elderly: Ethics and Quality Improvement

Healthcare Inequalities in the Elderly: Ethics and Quality Improvement. John R. Stone, MD, PhD Center for Health Policy and Ethics Creighton University Medical Center. Conflicts of Interest. None known. Learning Objectives. Explain evidence & racial/ethnic issues

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Healthcare Inequalities in the Elderly: Ethics and Quality Improvement

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  1. Healthcare Inequalities in the Elderly: Ethics and Quality Improvement John R. Stone, MD, PhD Center for Health Policy and Ethics Creighton University Medical Center

  2. Conflicts of Interest • None known

  3. Learning Objectives • Explain evidence & racial/ethnic issues • Describe an ethical framework • Explain implications

  4. Case 1: CML • Probability of being offered full spectrum of effective drugs • @ 75 versus @ 50 Stone 2012, Cambridge Quarterly of Healthcare Ethics

  5. Case 2: In Rehab • 80, depressedor sometimes irritable • Rehabilitation professional • Regard as positive as at 45? Stone 2012, Cambridge Quarterly of Healthcare Ethics

  6. Case 3: 65 Breast Ca_AA Woman • Excisional biopsy • Breast tissue conservation • Radiotherapy • Same % advice as if White? Stone 2012, Cambridge Quarterly of Healthcare Ethics

  7. Case 4: Rheumatology • “Aggressive” and “effective” care • Same for older as for younger patients? Stone 2012, Cambridge Quarterly of Healthcare Ethics

  8. Case 5-Chronic Disease • At age 72, will treatment be as established by research as at age 50? Stone 2012, Cambridge Quarterly of Healthcare Ethics

  9. Case 6: Institutional • Excellent tertiary hospital • Rigorous Quality Improvement (QI) • QI includes age-related care? • QI includes care per race/ethnicity? Stone 2012, Cambridge Quarterly of Healthcare Ethics

  10. Evidence Status • Need more studies • Existing data and care quality • Bad to be elderly • Worse to be elderly + racial/ethnic minority • Uncertain • (Probably) worse: elderly, racial/ethnic minority, poor

  11. Withholding Care & Ethics • Fair distribution among age groups • Unfair: merely because a person is old • Christine Cassel: illegitimate “implicit rationing” Cassel 2005

  12. If you’ve seen one 70 year-old… • “No ailment should ever be written off as an "old age" ailment. Treating patients based on their age means you can miss very significant, treatable situations. …If you've seen one 70-year-old, you've seen one 70-year-old. Mark Lachs 2010

  13. “Every patient is different, and I hate the way the health care system pigeonholes people based on a number, and it becomes more absurd as patients get to be 70, 80 and 90, with great variations in their functional ability.” Mark Lachs 2010

  14. Elderly Ageism • Bias, prejudice, discrimination, devaluation • Negative attitudes, stereotypes: dependent, grumpy, lonely, rude, stubborn, socially inactive, frail noncontributors* • Mistaken beliefs: asexual *Eymard & Douglas 2012

  15. Causes: Elderly healthcare disparities • Elderly ageism • Education/training deficit • Knowledge • Skllls • Insufficient Research • Inadequate review

  16. Causes: Elderly R/E Health Disparities • Stereotypes • Bias • Discrimination • Personal level • Institutional level • Policy level?

  17. Moral Framework • Respect for persons • Justice • Beneficence • Nonmaleficence/do-no-harm • Care • Solidarity

  18. Ethical Framework/Anchors

  19. Respect for PersonsNot just respect for autonomy

  20. Justice • Fair application of respect for persons and other professional ethical values • Health/healthcare equity • Remediation if unjust inequality or inequitable treatment

  21. Beneficence/Nonmaleficence • Advance the patients’ good • Do no harm when avoidable • Minimize harm • In light of respect for persons and justice

  22. Care • Needs of particular others/personal • Empathic/emotional connection • Thoughtfulness/considerateness • Focus on vulnerable/dependent • Attention to quality/groups Stone 2012, Cambridge Quarterly of Healthcare Ethics

  23. Solidarity • Alignment/unity/fellowship • Empathic bridging across distance • Opposes them/us • Focus: most disadvantaged Stone 2012, Cambridge Quarterly of Healthcare Ethics

  24. Foci of Equal Quality • Patients you see • Institution • System • State/nation

  25. Quality

  26. Race/Ethnicity Example • “I treat everyone equally.” • “I do not vary treatment quality with people’s race/ethnicity and so forth, but I attune to their individual needs.” • “My system/institution does not do quality assessments regarding race/ethnicity or age group.”

  27. Quality Improvement

  28. Quality Improvement • Age • Race/ethnicity • Other • Language • Gender • Socioeconomic status

  29. Quality Improvement/Elderly & R/E* Departments Institution Community *Disparities Solutions Center.

  30. RecommendationsImproving Attitudes & Views • Enhanced curricular content • Simulations: “The Aging Game” and others • Narrative reflection *Eymard & Douglas 2012

  31. Recommendations: Direct Care Sites • Open group inquiry/discussion • Iterative group value assertion • MMM: Mindful Mentoring & Modeling

  32. Recommendations • Individual clinician • Communicate, engage, connect, honor, empower • Care, empathize • Bridge cultural and age divides • Reflect (respect, justice, care, solidarity)

  33. Recommendations • Individual clinician • Mentor/model • Narrative reflection • Humility/self-critique

  34. Recommendations • Department/Division • Curricular content • Faculty development • Value clarification • Legitimize discussion

  35. Recommendations • Department/Division • Mentor/model • Promote QI • Promote elderly research

  36. Recommendations • Institution • Quality improvement • Community involvement • Department/Division inclusion • Elderly research

  37. Higher Levels • Policy review

  38. References • Cassel CK. (2005) Medicare Matters: What Geriatric Medicine Can Teach American Health Care. Berkeley: University of California Press. • Disparities Solutions Center. Massachusetts General Hospital. Boston. (See several documents regarding healthcare disparities.) http://www2.massgeneral.org/disparitiessolutions/resources.html#imqual • Eymard, A. S., & Douglas, D. H. (2012). Ageism among health care providers and interventions to improve their attitudes toward older adults: An integrative review. Journal of Gerontological Nursing, 38(5), 26-35. • Mark Lachs 2010: “Ageism in Medicine: How It Appears, Why It Can Hurt You: Interview with gerontologist Mark Lachs.” Maureen Mackey. AARP Bulletin. November 18, 2010. http://www.aarp.org/entertainment/books/info-11-2010/author_speaks_ageism_in_medicine.html (04Aug2012) • Powers, Madison; Faden, Ruth. (2006)Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford Univ. Press. • Stone JR. (2012). Elderly & Older Racial/Ethnic Minority Healthcare Inequalities: Care, Solidarity, and Action. Cambridge Quarterly of Healthcare Ethics.21(3), 342-352. • Stone, JR. (2012) Healthcare Inequalities in the Elderly. Ethical Times. Bulletin of the Program in Medicine & Human Values. California Pacific Medical Center. Sutter Health. 29(Spring), 1, 4-5.

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