Healthcare Inequalities in the Elderly: Ethics and Quality
Improvement
John R. Stone, MD, PhDCenter for Health Policy and
EthicsCreighton University Medical
Center
Conflicts of Interest• None known
Learning Objectives• Explain evidence & racial/ethnic issues• Describe an ethical framework• Explain implications
Case 1: CML
• Probability of being offered full spectrum of effective drugs– @ 75 versus @ 50
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Case 2: In Rehab• 80, depressed or sometimes irritable• Rehabilitation professional
– Regard as positive as at 45?
Stone 2012, Cambridge Quarterly of Healthcare Ethics
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
Case 4: Rheumatology• “Aggressive” and “effective” care• Same for older as for younger patients?
Stone 2012, Cambridge Quarterly of Healthcare Ethics
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
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
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
Withholding Care & Ethics• Fair distribution among age groups• Unfair: merely because a person is old
– Christine Cassel: illegitimate “implicit rationing”
Cassel 2005
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
• “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
Elderly Ageism• Bias, prejudice, discrimination, devaluation• Negative attitudes, stereotypes: dependent,
grumpy, lonely, rude, stubborn, socially inactive, frail noncontributors*
• Mistaken beliefs: asexual
*Eymard & Douglas 2012
Causes: Elderly healthcare disparities• Elderly ageism• Education/training deficit
– Knowledge– Skllls
• Insufficient Research• Inadequate review
Causes: Elderly R/E Health Disparities• Stereotypes• Bias• Discrimination• Personal level• Institutional level• Policy level?
Moral Framework• Respect for persons• Justice• Beneficence• Nonmaleficence/do-no-harm• Care • Solidarity
Ethical Framework/AnchorsRespect
for Persons
Justice
Care
BeneficenceDo-no-harm
Solidarity
Respect for PersonsNot just respect for autonomy
Respect for
Persons
Empower
Listen Humility
Engage Culture bridging
Recognize
Justice
• Fair application of respect for persons and other professional ethical values– Health/healthcare equity
• Remediation if unjust inequality or inequitable treatment
Beneficence/Nonmaleficence• Advance the patients’ good• Do no harm when avoidable• Minimize harm• In light of respect for persons and justice
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
Solidarity• Alignment/unity/fellowship• Empathic bridging across distance• Opposes them/us• Focus: most disadvantaged
Stone 2012, Cambridge Quarterly of Healthcare Ethics
Foci of Equal Quality• Patients you see• Institution• System• State/nation
Quality
Intent Outcome
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.”
Quality Improvement
QIIndicator
OutcomeAssessment
Remediation Reassessment
Quality Improvement• Age• Race/ethnicity• Other
–Language–Gender –Socioeconomic status
Quality Improvement/Elderly & R/E*
EvidenceEthical
FrameworkOutcomes
DepartmentsInstitution
Community*Disparities Solutions Center.
RecommendationsImproving Attitudes & Views
• Enhanced curricular content• Simulations: “The Aging Game” and others• Narrative reflection
*Eymard & Douglas 2012
Recommendations: Direct Care Sites
• Open group inquiry/discussion• Iterative group value assertion• MMM: Mindful Mentoring & Modeling
Recommendations• Individual clinician
– Communicate, engage, connect, honor, empower
– Care, empathize– Bridge cultural and age divides– Reflect (respect, justice, care, solidarity)
Recommendations• Individual clinician
–Mentor/model–Narrative reflection–Humility/self-critique
Recommendations
• Department/Division–Curricular content–Faculty development–Value clarification–Legitimize discussion
Recommendations
• Department/Division–Mentor/model–Promote QI–Promote elderly research
Recommendations
• Institution–Quality improvement–Community involvement–Department/Division inclusion–Elderly research
Higher Levels
•Policy review
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.