CHANGES IN SOCIETAL ROLES

Transcription

1 SOCIOECONOMICS OF AGING Keith A., Pharm.D., BCGP University of Oklahoma College of Pharmacy FACULTY DISCLOSURE Keith has no conflicts of interest to disclose. LEARNING OBJECTIVES At the conclusion of this application-based activity, participants should be able to: 1. Predict impact of societal and economic challenges on health status in the elderly 2. List major changes in support systems typically experienced during aging 3. Compare the impact of functional change on elders who have limited support systems 4. Contrast the goals and typical medical care interventions for palliative care against those of hospice care 5. Describe the components and effect on health care delivery for advanced planning tools including: living wills, do-notresuscitate orders, powers of attorney, guardianships, surrogates/proxies, advanced directives, trusts, and wills CHANGES IN SOCIETAL ROLES Employment to Retirement Parent to Grandparent (and back to parent/guardian) Spouse to Caregiver Spouse to Widow/Widower Independent to Dependent Higher Function to Lower Function Financial Stability to Limited/Fixed Income CHANGES IN ECONOMIC STATUS Retirement and net loss of income Variations in income sources Retirement savings Pensions Annuities Government programs Equity in family home Fixed Income vs. Increasing Costs Housing and food Taxes Medical insurance and co-payments Medications Transportation BROAD VARIABILITY IN FINANCIAL RESOURCES Geographic variation Urban vs. Rural Educational status Employment status Gender and race Marital status Health status Lifestyle expectations 1

2 CHANGES IN SOCIAL SUPPORT CHANGES IN FUNCTION Family transitions Mobility of grown children Declining health/death of spouse Loss of extended family Friends and neighbors Religious affiliation and organizations Civic organizations and clubs Health facilities and family doctors Support equated with positive emotions, greater purpose of life, lowered mortality Often initiated by health decline Changes self-perception and expectations Produces stress (loss of control) Fear influences decisions and quality of life Influences living environment and care services decisions Elder Living Environments Special Independent Living Communities Assisted Living Memory Care Long Term Nursing Care Home Health Care Respite Care In-home care aides and services CHANGING SOCIETAL SUPPORT SYSTEMS National programs and financial assistance Lack of knowledge, stress, and confusion Complicated requirements and application processes Burgeoning numbers influencing thresholds for receiving assistance Health status Indicator of well-being Predictor of societal and personal expenditures Influenced by health care actions and supports CHANGES IN COPING MECHANISMS Generational Standards Greatest Generation Boomers Self-reliance Substance use and abuse Reliance on medical, mental and cognitive care services and alternate health practices Expectations and respect for health providers SOCIETAL EXPECTATIONS FOR CARING FOR ELDERS - ETHICS OF CARE Autonomy: Respecting the rights of a person to make decisions regarding their care Beneficence: Responsibility of the caregiver to make good choices, to do good Nonmaleficence: Responsibility of the caregiver to do no harm SOCIETAL EXPECTATIONS FOR CARING FOR ELDERS - ETHICS OF CARE Justice: The responsibility of the caregiver to treat patients fairly, without prejudice, and founded on medical needs Self-determination: Responsibility of the caregiver to recognize the rights and needs of clients to be free to make their own choices and decisions. 2

3 Abuse: IMPACT OF ELDER ABUSE/NEGLECT Actions intended to cause harm or risk of harm to an older adult Done by person in a trusting relationship with that older adult Includes failure to supply needs or protect the older adult from harm Neglect: IMPACT OF ELDER ABUSE/NEGLECT Failure by a caregiver or other responsible person to protect an elder from harm Failure to meet needs for essential medical care, nutrition, hydration, hygiene, clothing, basic activities of daily living or shelter Results in a serious risk of compromised health and safety. SIGNS AND SYMPTOMS OF ELDER ABUSE/NEGLECT Physical: Unexplained bruising, fractures, burns, abrasions or sores Sexual: Bruising around the breasts or genitalia, infections Emotional: Social withdrawal, depression, isolation, frequent arguments with caregiver, and behavior of caregiver toward the older adult SIGNS AND SYMPTOMS OF ELDER ABUSE/NEGLECT Financial: sudden change in finances, not able to afford food, heat, clothing Neglect: Pressure sores, dehydration, disheveled appearance, lack of hygiene, weight loss ADDRESSING ABUSE & NEGLECT Reporting Family Facility administration Law Enforcement Support systems Protective Services Ombudsman END OF LIFE ISSUES Hospice and Palliative Care Decision-making in advanced disease Do-Not-Resuscitate (DNR) orders Living Wills and Advance Directives Designating Decision-makers Power of Attorney Surrogate/Health Care Proxy Guardianship 3

4 HOSPICE CARE Increasing Comfort Care Focus - symptom and pain management Decreasing Curative Care Focus - withdrawing non-essential interventions Generally offered for terminal conditions (final 6 months) Medicare Benefit since 1982 Hospital/ED admissions avoided except for easily corrected acute conditions that affect patient comfort Implementing support services for patient and caregivers Health Social Spiritual PALLIATIVE CARE Patient goals direct all decisions requires communication Focus on BOTH Comfort Care and Curative Care Reducing negative impact and risk from overlyintensive care at all points of terminal illness (no time constraints) Support services for patient, family, and caregivers Hospitalization/ED visits still an option HEALTH ISSUES IN PALLIATIVE CARE Weight loss/decreased appetite Anxiety/Depression Constipation Delirium/Cognition changes Dyspnea Nausea Pain ADVANCED CAREPLANNING Requires active discussions between patient, caregivers, clinicians Tools and talking points Advanced Directives Living Will Durable Power of Attorney Proxies and surrogates Do Not Resuscitate Order Guardianships Financial issues: wills and trusts, cost of institutional care SOCIETAL PERCEPTIONS OF AGING Ageism: stereotypical discrimination against older individuals or groups Prejudicial attitudes Discriminatory practices Institutional policies and practices Statutes and regulations CASE #1 SUMMARY A 93 year old WWII veteran is moved from his apartment attached to his daughter s home into a veterans home after having suffered 4 falls over two months. He was living with his daughter s family after depleting his savings over the first 20 years of his retirement. His wife died following a stroke 12 years ago at age 79. Following the last fall, his family had to call Emergency Services to provide assistance helping him up to his feet. He shares his semi-private room with a man 30 years younger than him who suffered a brain injury during the Vietnam War. His room mate is unable to speak and spends all his time in bed. Our patient attends several activities at the facility each week and is seen in the physical therapy department three times a week. 4

5 CASE #1 CLINICAL SITUATION His physician is considering starting an antidepressant due to complaints of insomnia and reduced levels of energy. When questioned, our patient says, The folks here are nice enough, but I miss going to my church on Sundays and attending my Tuesday Morning Bible Breakfast with the guys on Tuesday mornings. Over the past 2 months he s lost approximately 13 lbs (5kg) and is now using a wheel chair instead of the 4 leg walker he used at home. His medication list includes: metoprolol, furosemide, potassium chloride, and acetaminophen for arthritis. REFLECTION Does this situation sound familiar? What other issues would you expect to find if we dig deeper? What additional information do you need? QUESTION 1: Which issue is primarily responsible for his recent change in living arrangements? A. Change in economic status B. Change in family support C. Change in physical function QUESTION 2: Which socioeconomic issue is exerting the greatest influence on medical care decisions at this time? A. Reduced financial resources B. Reduced social interaction C. Loss of social supports QUESTION 3: Which end of life tool would be most helpful in guiding the medical team s decisions regarding the initiation of additional therapies? A. Advanced Directive for Health Care (Living Will) B. Do-Not-Resuscitate Order C. Durable Power of Attorney QUESTION 4: Our patient is refusing morning doses of his metoprolol because he feels lousy during the day after taking it. What ethical principles should guide the team s decisions when addressing this issue? A. Autonomy and Nonmaleficence B. Beneficence and Justice C. Justice and Self-determination 5

6 QUESTION 5: Which model of advanced life care is most likely applicable in this situation at this time? A. Hospice Care B. Palliative Care C. Respite Care ROLE OF THE PHARMACIST IN ASSURING OPTIMAL CARE Assessing socioeconomic influences impacting delivery of optimal health care Anticipate changes in condition and support systems that negatively impact patient function and increase risk and mortality Recommending interventions: Think Must Should Could Might QUESTIONS? 6