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Ethical crossroads in elder care

by Isabel Fawcett, SPHR

Current healthcare news is increasingly focused on the skyrocketing costs of treating chronic illnesses while finding ways to reduce eldercare costs. Acute care has long grappled with ethical issues in medical gerontology. There may be far more questions than answers, however, as the aging population explodes.

High-Risk Elders

In the age of healthcare reform, the terminology of high-risk has been expanded to include chronically ill and frail elders whose illnesses are costly to treat, including greater medical staff time. Some have proclaimed that acute care is ill-prepared to handle the anticipated boom in high-risk, chronically ill elders. I am not convinced.

Even as the federal government increasingly speaks of re-directing training support to doctors, nurses and other healthcare staff, my front-line carer's observation is that acute care may be better prepared than some may think. Quite literally speaking, elders were not born yesterday. Acute care and long-term care have always been strategic business partners in eldercare.

Tough Ethical Choices in Eldercare

One of our family friends had to be readmitted to a local hospital twice this year. She has endured three major hip-related surgeries in one year. Her bones are brittle- too brittle to support the artificial hip replacement in her body. Odds are slim that her hip replacement and subsequent corrective surgeries will be successful.

After one of her hip-related surgeries, she fell while hospitalized. Once she fell she could not walk for months, even with daily physical therapy and extended rehabilitation. Eventually, even with help, she could barely lift her body to use her walker. It is easy to envision the high cost of care involved in such situations.

Our friend is clear that she wants to keep trying. The alternative is depressing and frightening to her, as it is to me. She was clear when she perceived no encouragement from her assigned physical therapist. Her family felt that the hospital wanted her discharged to a nursing home. She was adamant that she would not go to a nursing home. Thus the acute care and family standoff continued for a short time.

Two months into her first hospitalization, our friend and her family insisted that she not be discharged from the hospital until her body had more fully recuperated. Her family recognized the obvious. She was not well enough to be discharged from the hospital. She was a candidate for in-home assistive care.

Hospital Readmissions Scrutinized

Under the 2010 Patient Protection Affordable Care Act (PPACA) within two years of enactment, the Department of Health and Human Services is required to develop reporting requirements that will support implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge, which must include patient education and counseling.

Doctors and Hospitals Have Not Been Remiss

My first hand observation in more than a couple of states where I have lived and worked is that patients are being educated and counseled, including with specific emergency department discharge instructions, in some instances. As a former Americans With Disabilities Act Coordinator, my interactions with some American workers seems to suggest that their doctors and nurses are doing a superior job of counseling and educating those patients. In addition to vast technical resources available online from reputable organizations, there is no shortage of patient education and counseling. Without medical counseling and solid patient information, I, for one, would not be capable of providing complex in-home assistive care to my mother. I do understand that there are others who may not be on the receiving end of such patient education, however.

Preventing Hospital Re-admissions?

Using my friend's situation for illustrative purposes only, it is unclear what else could have been done by her highly involved medical care team to prevent her from being readmitted to the hospital in such a short time after she had been discharged.

Her healthcare team was patient-focused, convened regularly about her care, prognosis, and daily planned her tentative discharge from the hospital. Maybe I am missing something, but I don't see how the hospital could have discharged her any sooner given her complicated medical history, current symptoms, recurring falls and more.

As my friend is mentally sharp, her ability to think for herself and speak up about her hospital and rehab care was not popular with the treating hospital and healthcare team. Eventually, she was discharged to her home with the stipulation that she required 24-hour in-home nursing care. A social worker physically visited her home in advance of her discharge to ensure that she could be cared for safely in her home by skilled nurses.

Less than a month after returning to her home, our friend is back in the hospital. She is now recovering from a third corrective surgical hip procedure. In our brave new healthcare reform world, our friend is a high-risk elder due to her chronic and declining health, the high cost of her medical care, and the challenges she poses in acute care settings.

Preventing some hospital readmissions is a nice theory and ideal healthcare outcome. In some instances, skilled and caring doctors, nurses, social workers, and other healthcare professionals are doing, and have done all they could to counsel, educate and safeguard elders' best medical interests. When that is the case, my take is no different than my personal life philosophy. Having done our best, angels can do no more. There is such a thing as overkill, including how acute and long-term care are regulated, sometimes over-regulated.

Someone needs to keep it real.