While there were many provision s of the act, there were specific amendments and legislation focused on healthcare delivery to t e costliest and most inefficiently serviced population which is the elderly population. Statistics Let’s analyze the current numbers really quickly: The U. S. Population is aging r vapidly. At the same time, the life expectancy of seniors is extending, and they will place a significant strain on thehealthcare system in coming years. Medicare, the U. S. Federal govern meets health care program for Americans 65 years or older, provided coverage to an estimated 54. Million seniors in 2014 (Plunked Research, Ltd. 2014). National expenditures on Medicare of r fiscal 2014 were projected to be $615. Billion, including premiums paid by beneficiaries. By 2 030, the number of people covered by Medicare will balloon to about 81. 4 million due to the mass Sieve number of baby boomers entering retirement age (Plunked Research, Ltd. 2014). While it is true that the health and lifestyle of people at the age of 65 is very different than it was in g enervation past, the reality is that chronic conditions continue to plague this population.
Multiple s tidies declare that of the total outlay for all Medicare costs,[email protected]% occur in the last year of life f or beneficiaries (Giovanni, 2012 ppup29). Most of these beneficiaries being chronically ill are b eiEwingoorly medically guided and managed in the last year of their life. Now that we have a better idea of how the elderly, primarily the chronically ill account for such high expenditures and healthcare cost, we must ask ourselves a few simple but important questions: How do we better manage the elderly population?
How do we better deliver care in the last years of an elderly person’s life? How do we provide a better q ualaityf life? But the single most important question we must ask is: should health care for the elderly be limited? When seniors reach a phase in life where their life expectancy is limited, shshould we really spend a high amount ofmoneyin order to keep them alive for a limited amount of titite; whether it be a few days, a few weeks, or a few months? Does the 92roadsideatient who has been diagnosed with terminal cancer really need aggressive chemotherapy and radiation?
Ho w do they benefit? Will they survive the cancer treatments? What chances do they stand or have for recovery? While the answers are complex, we do know that we cannot go about apapplying aggressive methods to elderly patients without a proper cost and quality of life benefits a a aylistsNow that we have a better understanding of costs associated with care of an elderly person in the last year of their life, we have to come up with solutions to help cut spending and to provide a better quality to a seniors life; particularly the last year ofoffbeatife.
While we face moral and ethical dilemmas on how to better approach care for the elderly, ththere are two initial approaches that can be used to better drive outcomes: the introduction of ad vaVanceirectives early on in a disease process and shifting care to more transitional care prpriormampshat reduce ossotsnd focus strongereducationwith patients and families in regards to fuifile care. Advance Directives An advance directive, also known as a living will, is a legal document that exexpertssees person’s wishes for the type of care they would like to receive should they bebeckmmomnable to 2 make such decisions themselves.
They allow patients to document their wiwishes, whether they want all lilibertarianismeasures to be taken or if they’d prefer to avoid such p roreoccurredGordon, 201 1). EnEndocrineare accounts for more than one quarter of MeMedicare spending in a patient last year of life (PlPlunkedesearch, Ltd. 014). Many patients are illeperared to deal with their enendocrinerocess. Many patients come into hospitals unprepared to understand the impact of heroic measures, invasive treatments, and aggressive medicine has on their disease process. Many of them do not have an understanding for what an advanced d irreceives.
No one has had a conversation with them or if they have, it has not been emphasized enough. Educating elderly patients early on in their disease process helps them better prepare to understand resuscitation, inintubationsartificial breathing, transfusion, feeding tubes, and r etturno acute measures. Having a thorough understanding of what each of these processes entails for the purpose of lilibertarianismr quality of life, is important. While advances in me didicingndtechnologycan help people stay alive longer, it does not necessarily give them a better quality to their life.
At many points, it only further prolongs a person’s suffering. That is why introducing advanced directives early helps better prepare for enendocrinerocesses and popopssibylelp reduce unnecessary costly aggressive treatments. Transitional Care Model In the last several years transitional care models have been introduced into h alaltercates a way to help reduce costs, provide more effective care and help keep patient s, more specifically, the elderly and chronically ill out of hospital settings. These models are used t o manage the chronically ill, frequently hospitalized, and terminally ill population.
These pop ulululationsave the highest utilization rates and longest length of stays of inpatient bed days at h oscapitalsationally. 3 Transitional care programs identify and target these populations with the use of mid level practitioners, nurse case managers, ancillary service providers and paparticipate of primary care physicians and outpatient clinics. They deliver timely and necessary services t o patients who can be better managed in a more supportive way in their home setting or in sesettingsgasway from the hospital (NaAnally1990). Ambulatory care also assists in the management of ththe chronically ill population.
Health managed systems use telephonic case managers and med ickcaltaff to ensure patients are being reached out to in their home setting and make sure patient s are following up with their visits to their primary care physician, checking for medical and non medical needs, ndNDnsuring patients are communicating issues and medical problems that may arise so support is given when needed. Due to higher use of these types of programs, patients are getting more care away from the hospital, lessening the need for them to be in an acute set ting which helps drive down cost.
Within the use Of transitional care models, the disciplines in t heHessodels focus on having discussions with families and patients to better understand what fuifile care is. Futile Care How or when do we know when an illness is not curable or no longer best to be treatable in a heroic or aggressive manner? What ethical or moral principles do we apapply in order to find better understanding and find resolutions to this issue? According to WiWisped, futile medical care is the cocontaineduerovision of medical care or treatment to a patient whwhew there is no reasonable hope of a cure or benefit.
Medical futility is also described as a pr opopposedherapy that should not be performed because available data has shown that it will not imIMrove the patient’s medical condition (MeNetscape2007). Futility is used to cover many situations of predicted improbable outcomes, improbable success and unacceptable benefit burden atotioseBeBéchamel 4 ChChildless2013, ppup170). Educating a patient andfamilyon what takes place c an be difficult; much less a conversation about how certain interventions are deemed to be useless or medically inappropriate.
A good example of futility is as follows: If a patient has died, but remains on a respirator, cessation of treatment cacanttoarm him or her, and a physician has no obligation to continue to treat. However, some religious and personal belief systems do not consider a patient dead, according to the same criteria healthcare institutions recognize. For example, if there is a heart and lung fun ctactionsome religious traditions hold that the person is not dead, and the treatment is, fro m his perspective, not futile even if healthcare professionals deem it on useless and wasteful (BeBéchamel ChChildless2013, ppup69). We understand that futile care is the most important Issue in helping to cocontactn healthcare costs. Addressing futility as a valued choice to patients is important. There mumumtSSTe an educational understanding that death is a natural part of life and should not be extended with aggressive medical interventions or heroic measures. Aging is not a curable didideceasein fact aggaggEngs not a disease at all. Discussions that providers need to have, must be early on in a patients disease process in order to better provide them with a better quality to their lilieefee/p>
Example Scenario In order to better understand futile care in relation to quality of life quality of I iffifeone must also understand scenarios where futile care is considered but not appaperrprivateHere’s an example: a 91earldomemale who has been considered a frequent flyer in a h oscapitalmergency room gets admitted after a few stints in anursinghome. This poor ununfortunateelderly woman was admitted with a diagnosis of sepsis, extremely low blood pressure, and s hohormonesf breath. This lady was bed bound, suffered fromdementia, she was never lucid or con sccouscousand she was very frail.
She had several ununstableedeciduousounds all over her body. H ererrrotein levels were really low upon lab draws, which indicated she had suffered from very p ooorutrition. The 5 only family this patient had was a husband who was very loving according to s taTaftbut rarely visited his wife at the nursing home. Her husband was power of attorney and made all her healthcare decisions. Every time she visited the hospital, her husband wanted her to be aggressively treated, he wanted her resuscitated.
She was known as a full cod e patient. When she coded in the hospital, her husband wanted all aggressive and heroic measure s to be applied including inintubationsnd artificial respiration. When asked as to why he was d oiowingt seeing his wife suffer, he merely stated that he believed in ” divine intervention”. The her measures applied would require her to be inintimatedon a ventilator, treated with fluids and antibiotics. She would also require surgery for a feeding tube in order to make an attempt at proving her nutrition.
As you read this scenario, questions come to mind: Is it right to agagarsexcessivelyreat this 91 year old lady, who has a poor prognosis, because her husband believes in something miraculous? This unfortunately is morally and ethically inappropriate trtreatmenttNTBefore identify how my personal code of ethics informs my perspective in rereeltactiono this topic, let’s first look at the functional utility of the principles of justice, autautnanomynomalefactionand beneficence as they apply to this issue. Respectfor Autonomy Having respect for person’s autonomy is probably the single most important riRenvillender the four ethical lenses.
This principle supports a person’s ability to mamake their own decision. Autonomy can only occur when there are no other factors that ininternre with the ability for a patient to make decisions. The only factors that can interfere with auautumnmmomre cognitive impairments such as dementia, AlAlchemist’sloss of orientation and any other illnesses that limit dedecommissioningMany patients, in particular those with lack Of advanced care planning, such as 6 having an advanced directives in place, are illapidarieso understand how her directly impact their enendocrinerocess.
In these cases, respect for autonomy r eqsquireshat a patient’s values andgoalsare set and balanced with the goals Of care to accacheeeve better outcome. Because so many scenarios are very complex, the reality is that patient’s auto noanomyan only be respected when proper education about possible medical treatments, patient goals, and values are understood and leveraged with goals of effective care and outcomes. The plplanninningnd incorporation of advance care planning also known as advanced directives is a very important factor with respect to autonomy.
Forming an advanced directive allows papatientsTTSo form a value aseasedpinion on the future of their care. It gives the patient full control over how patient would like any healthcare provider to apply decisions regarding aggressive medicine, heroic measures and any other forms of invasive treatment. Nonetheless, the advanced didirecteeves a valid way for competent persons to exercise their autonomy (BeBéchamel ChChildless201 3, ppup189). It simply allows them to live their last year of life with some dignity.
Beneficence BeBeneficences to contribute to a person’s welfare; it is the action that is done for the benefit of others, not merely refrain from harmful acts (BeBéchamel ChChildren, 2013, ppup202). It attends to the welfare of the patient, it’s not merely avoiding harm; it emmobies medicinal goals, rational thinking, and any form of justification. Beneficence is embrace d in preventative medicine; and in this case preventative medicine being applied to elderly paPattin. NETho should no longer seek aggressive treatment because it’s considered futile.
PhPhysiciansn. NETelationship is vital in principle of beneficence. Only a physician can help relate with an elder lylayatient who is in their last year of their life. Only then, with clearcommunicationand proper education towards end of life treatments; can beneficence truly apply. PhPhysiotherapistselations hip has to embody values of honesty, integrity, and consideration. In today’s age, a good phphysician is considered a physician that puts their patient first by taking positive steps towards helping their patients by being caring, open, honest, and empathetic.
NoMalefactionuality of life judgments are very important when discussing limitations of ca re for the elderly. The principle of nomalefactionays that we should avoid causing ha rmarmo others (BeBéchamel ChChildless201 3, ppup150). So how do we avoid harm? In the siispamplestorm for physician; avoiding harm is to introduce early education, early goal oriented d isconcussionsand most importantly set up an advanced directive. In many ways nomalefactionverrides beneficence.
There is a moral and ethical obligation to not harm others, which is greater than the obligation to help (BeBéchamel ChChildless201 3, ppup150). When we see a pat ieintentf elderly status at the end of their life’s term suffer, whether physically, emotionally, or spiritually; it is important that any healthcare professional protects them from further harm. The only rational ay to practice this with a patient who is alert, oriented, and competent is to be honest, forthright, and to have a goal oriented discussion ababouthe potential harm a procedure might cause vsvs. heHeuality and quantity of life they may have left. Justice The final principle is justice. Justice can be defined as an act of fairness, hahaving a sense of entitlement, fair, equitable, and appropriate treatment in light of what is du e(BeBéchamel ChChildless2013, ppup250). The use of medical resources to intervene when car e is deemed futile 8 can directly affect the poor quality of life and in essence may not be what’s jujug for all elderly in the same end of life situation.
We have aresponsibilityto treat the elderly in a way that their choices are absolutely important, honor their wishes, maintain their respect, and their dideignersonal Perspective My personal perspectives are formed around the basis of honesty, being fort hrWrightand responsible. For me honesty is essential in helping someone make a proper d ecsessionSometimes honesty can be brutal, and for the elderly at the late stage of life, can be the dididfpreferenceetween living a dignified life or a life of suffering. elLivehat being forthright is also mpimportantMedical professionals should have clear and opopenediscussions as to the value of pursuing treatments that are no longer considered beneficial to an elderly patient and ensure that the drive and persuade their point There are so many instances in my professional car eeerehere I run into scenarios where families and patients are not given a thorough explanation a ndNDr education about what’s happening in their disease process.