John R Stone MD PhD Center for Health Policy and Ethics Creighton University Medical Center Conflicts of Interest None known Learning Objectives Explain evidence amp racialethnic issues Describe an ethical framework ID: 676784
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Slide1
Healthcare Inequalities in the Elderly: Ethics and Quality Improvement
John R. Stone, MD, PhD
Center for Health Policy and Ethics
Creighton University Medical CenterSlide2
Conflicts of Interest
None knownSlide3
Learning Objectives
Explain evidence & racial/ethnic issues
Describe an ethical framework
Explain implicationsSlide4
Case 1: CML
Probability of being offered full spectrum of effective drugs
@ 75 versus @ 50
Stone 2012,
Cambridge Quarterly of Healthcare EthicsSlide5
Case 2: In Rehab
80, depressed
or sometimes irritable
Rehabilitation professional
Regard as positive as at 45?
Stone 2012,
Cambridge Quarterly of Healthcare EthicsSlide6
Case 3: 65 Breast Ca_AA Woman
Excisional biopsy
Breast tissue conservation
Radiotherapy
Same % advice as if White?
Stone 2012,
Cambridge Quarterly of Healthcare EthicsSlide7
Case 4: Rheumatology
“Aggressive” and “effective” care
Same for older as for younger patients?
Stone 2012,
Cambridge Quarterly of Healthcare EthicsSlide8
Case 5-Chronic Disease
At age 72, will treatment be as established by research as at age 50?
Stone 2012,
Cambridge Quarterly of Healthcare EthicsSlide9
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 EthicsSlide10
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, poorSlide11
Withholding Care & Ethics
Fair distribution among age groups
Unfair: merely because a person is old
Christine Cassel: illegitimate “implicit rationing”
Cassel 2005Slide12
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
2010Slide13
“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
2010Slide14
Elderly Ageism
Bias, prejudice, discrimination, devaluation
Negative attitudes, stereotypes: dependent, grumpy, lonely, rude, stubborn, socially inactive, frail
noncontributors
*
Mistaken beliefs: asexual
*
Eymard
& Douglas 2012Slide15
Causes: Elderly healthcare disparities
Elderly ageism
Education/training deficit
Knowledge
Skllls
Insufficient Research
Inadequate reviewSlide16
Causes: Elderly R/E
Health Disparities
Stereotypes
Bias
Discrimination
Personal level
Institutional
level
Policy level?Slide17
Moral Framework
Respect for persons
Justice
Beneficence
Nonmaleficence/do-no-harm
Care
SolidaritySlide18
Ethical Framework/AnchorsSlide19
Respect for Persons
Not just respect for autonomySlide20
Justice
Fair application of respect for persons and other professional ethical
values
Health/healthcare equity
Remediation if
unjust
inequality
or inequitable treatmentSlide21
Beneficence/Nonmaleficence
Advance the patients’ good
Do no harm when avoidable
Minimize harm
In
light of respect for persons and
justiceSlide22
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 EthicsSlide23
Solidarity
Alignment/unity/fellowship
Empathic bridging across distance
Opposes them/us
Focus: most disadvantaged
Stone 2012,
Cambridge Quarterly of Healthcare EthicsSlide24
Foci of Equal Quality
Patients you see
Institution
System
State/nationSlide25
QualitySlide26
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.”Slide27
Quality ImprovementSlide28
Quality Improvement
Age
Race/ethnicity
Other
Language
Gender
Socioeconomic statusSlide29
Quality Improvement/Elderly & R/E*
Departments
Institution
Community
*Disparities
Solutions Center.Slide30
RecommendationsImproving Attitudes & Views
Enhanced curricular content
Simulations: “The Aging Game” and others
Narrative reflection
*
Eymard
& Douglas 2012Slide31
Recommendations: Direct Care Sites
Open group inquiry/discussion
Iterative group value assertion
MMM: Mindful Mentoring & ModelingSlide32
Recommendations
Individual clinician
Communicate, engage, connect, honor, empower
Care, empathize
Bridge cultural and age divides
Reflect (respect, justice, care, solidarity)Slide33
Recommendations
Individual clinician
Mentor/model
Narrative reflection
Humility/self-critiqueSlide34
Recommendations
Department/Division
Curricular content
Faculty development
Value clarification
Legitimize discussionSlide35
Recommendations
Department/Division
Mentor/model
Promote QI
Promote elderly researchSlide36
Recommendations
Institution
Q
uality improvement
Community involvement
Department/Division inclusion
E
lderly researchSlide37
Higher Levels
Policy reviewSlide38
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.