Introduction
As a result of better healthcare, people worldwide are actually living longer especially in the developing world. Thus, for the first time in history, people aged over 65years are more than infants aged less than five years. In fact, it is estimated that by the year 2030 (approximately two decades from now), the population of the aged in the human society globally would have hit the one billion figure. This figure represents an eighth of the current global population. More so the increase will be higher in the developing world whereby it is expected that by the year 2030, the aged population will increase by a whopping 140%. This is not only attributed to the improving healthcare standards universally but also the declining birth rates in a bid for most economies in the world to mitigate the rapidly exponentially growing populations. For instance, the one-child rule in China has had drastic impacts on the country’s demographic characteristics. In fact, according to WHO (World Health Organization), non-communicable diseases are claiming more lives than communicable ones.
This longevity however comes with its own challenges. First, as the number of the aged in the society increases, this implies that the number of healthy people in the society in rapidly diminishing. This is solely attributed to the fact that old age comes with its own challenges emanating from the inability of the immune system to combat disease and the failing of vital body organs ranging from the brain to the feet. Most of these medical conditions that come with old age are not easy to diagnose and henceforth go unnoticed till they have progressively advanced and are more challenging to cure or manage. For instance, compared to the current threats to human lives (cancer and HIV/AIDS) the prognosis of old age medical conditions such as cardiovascular disease, dementia and Alzheimer’s disease, arthritis, and diabetes are less detectable and expectable. The progressive nature of old age diseases also makes it difficult to manage them effectively. As a result, the end-of-life care providers in most countries are overwhelmed. In fact, only the UK (United Kingdom) has an enviable end-of-life care community that countries such as Australia and USA are advancing towards emulating. In fact in most parts of the world, the end-of-life healthcare services are either non-existent or at their infancy stages. This is as a result of the fact that most countries in the world have focused on preventing death and completely neglected helping their citizens die dignified deaths devoid of pain, suffering and distress. The thesis shall hence dwell on end-of-life care services around the world, the arising challenges and how best to combat these challenges.
Most cultures in the world viewed death ominously; as a result it is a taboo to talk about it. For instance, talking about death is a taboo in the Japanese, Chinese, Indian and African cultures to mention but a few. In places where death can be discussed in the public domain, religion, tradition and sometimes philosophy advance the notion of reincarnation and a second life after death henceforth effectively dealing with the fear of death in the society. Coupled to this, most societies worldwide believe that talking about death and even accepting it is a bad omen. To this effect, Indians can avail themselves to care for their dying relations but are reluctant to disclose the nature of the patient’s ailment. In fact, Indians completely avoid letting the patient know that their life is on the demise. These cultural challenges have also been met in London due to the cosmopolitan characteristic of the city. Healthcare givers have experienced challenges while rendering their services to people of Somali descent because they cannot accept death and do not want to know that they are about to die. Thus, healthcare providers have had to develop strategies to provide end-of-life care to them without even hinting at the possibility of death.
On the other hand, taboos related to the death of children are more prevalent in the developed world compared to the developing world. In fact, in the developing world infant mortality rates are hence have come to be taken as the normalcy unlike in the developed world where infant deaths are unacceptable and treated ominously. However, in both worlds, people generally tend to shy away from speaking about the death of children. Finally, in the US the end-of-life care services are deeply entrenched in the culture of capitalism and religion that the country is renowned for. The sanctity of life that most religions in America believe in has made them oppose the euthanasia bill that is targeted at improving the end-of-life care in the country. Also, the religious and fundamentalist Americans are more likely to rely solely on the doctor’s recommendations and not think outside the box. Also, there is this notion in USA a cure must be reached at all costs that is favored by American doctors. This is evident in the fact that a doctor can recommend expensive medical care services that have no effect whatsoever on the patient’s wellbeing.
End-of-life trajectories for older people
Healthcare strategies directed at combating death have been successful worldwide. This implies that people globally are living longer and in fact Japanese and Australians have been found to have the highest life expectancies; 83 years and 82years respectively for both male and female in these two countries. However, between the years 2004 and 2005 empirical studies conducted in Australia established that 77% of the Australians have had a health disorder of some kind that lasted for six months or more. Therefore, it is clear though people are living for long; most of them are battling with one chronic illness or another. So as a result one in every three Australians has a chronic illness which loosely translates to 7million Australians. Also, it has been determined that the leading causes of mortality amongst senior citizens in Australia include cancer, cardiovascular, respiratory system, endocrine and genitourinary disease. To this effect, WHO estimates that by 2030 the leading cause of death globally would be ischemic heart diseases, strokes (cerebrovascular diseases) and COPDs (chronic obstructive pulmonary diseases). This implies that as time goes by, death is being delayed and is becoming more complicated because in practice one has to battle with more than one chronic illness whose prognosis and management can be challenging on many levels.
The other challenge characterized with these chronic illnesses that are gaining popularity globally is the fact that most of these disorders are diagnosed multiple times inconclusively. Therefore, medical experts have categorized chronic and fatal disorders amongst the elderly into the following categories. First, people who exhibit a short period of marked health deterioration. This category refers to people suffering from health disorders such as cancer whereby the symptoms are only obvious when the disease is far advanced for any form palliative care to make a difference. The second category comprise of people suffering from long-term illnesses that are characterized by sporadic severe bouts. In this case a person harbors a disease in their system for so long that periodically rears its ugly head and eventually this person dies from unexpected complications as a result of the seasonality of the severity of the disorder. Such disorders include cardiovascular disorders and diseases characterized by human body organs failure. The final category comprises of health disorders with a dwindling trajectory. In such cases, one’s health is characterized by multiple progressive organ failures that result to diminished capacity of the immune system as the years pass by. Most of these result to death several years after prognosis and when the patient has long lost the ability for self care.
Thus, from the aforementioned categories, it is clear that health disorders amongst the elderly are riddled in uncertainties that make their effective management and decision-making on the best way forward difficult and complicated. This implies that the ability of the patient, doctor or the families of the patients to make informed decisions based on accurate prognosis is greatly impaired in the case of the elderly. This is further complicated by the fact that people react to illnesses and old age differently. Denial however, is the most preferred reaction by most people across the globe. In addition to this, empirical data reveals that dementia related health disorders are the most common of the three categories of chronic illnesses that are prevalent amongst the elderly. It is in fact estimated that by the year 2030, the numbers of dementia related will increase by a staggering 150% from the present day figures. However, it is important to mention that despite the high degree of uncertainty as far health disorders amongst the elderly is concerned; there are universally accepted standards on what end-of-life care services should comprise of. Thus a comprehensive end-of-life care system should comprise discussions about the probable best applicable end of life approaches, assessment, planning and review of the care, coordination amongst different stakeholders, quality based care, and finally care both before, during and after death.
End-of-life care and decision-making
It is normally challenging to determine who can and who cannot make decisions for or against end of life. In North America and several parts of Europe, this is normally based on the principle of autonomy. As a result, efforts should be made to ensure that the power to make autonomous decisions rests on the right individuals. Also, the principle of autonomy should be empowered in such a way to ensure that it is above ethical considerations. This is because the biggest challenge to the end of life decisions is the ethical beliefs upheld by the human society. The principle of autonomy thus advocates that medical ethics should be based on the involvement of the patient and their respective loved ones if the competency of the patient cannot be relied upon in the decision-making process. Since the most common health disorders amongst the elderly are dementia related, this might pose significant challenges to the principle of autonomy as far as decision-making is concerned.
Thus, competency can be simply be defined as the mental capacity that enables one make informed decisions. This implies that competency is both based on legal as well as clinical frameworks. Generally, one cannot be termed as being incompetent based on the decisions they make as far as end of life care is concerned. Sadly, the case is competency to make medical decisions is based on the outcome rather the process and the considerations taken into account during the decision-making process. Thus, in real life scenarios, whenever one makes medical decisions contrary to what their doctors or loved ones have in mind, this person is termed as being incompetent. This system is not fair because one competency as far as decision-making capacity is directly related to the subjective opinion held by other involved parties. Since competency is related to the ability to perform specific tasks, the criteria of ascertaining incompetency in patients thus varies from patient to patient based on the nature of decisions made and the degree of dementia the specific patient is exhibiting. It is also clear that the decision-making ability varies as the illness advances and as time passes.
Thus, the assessment of a patient’s competency should be solely left to the doctor’s discretion. This is because healthcare givers interact with the patients more closely and intimately as they battle their various illnesses compared to their loved ones. This assessment can either be informal or clinical based depending on the situational circumstances. This is more viable because whenever the doctor’s assessment is contrary to the patient’s or their loved one’s opinions then they can always seek a second opinion from a different physician all together. Whenever medical practitioners effectively ascertain a patient’s incompetency, either of the following can happen: the entire patient’s decision making privileges can be revoked and passed over to competent surrogates or guardians or the patient might be forcibly institutionalized to give the healthcare the right to make decisions on behalf of the patient. Finally, incompetency should directly correlate to a patient’s mental status.
End-of-life care planning process and decision-making
End-of-life care planning is commonly referred to as Advanced Care Planning (ACP) directed at enabling especially the competent elderly to document their end-of-life wishes and their medical preferences in anticipation to incompetency. This program respects the fact that older people and their respective families need to be involved in decision-making as far as end-of-life care is concerned. This is because whenever the patient or their family members are unprepared for death, decisions made to end their lives are normally characterized by “distress, guilt and regret as the concerned parties make emergency decisions as to what appropriate end-of life strategies should be adapted.” This is also complicated by the fact that whenever an elderly is incompetent, their loved ones are not usually equipped to make the tough decisions required to end their lives due to emotional attachment. This just further goes to stress the need for ACP program. Finally, there might also be discord amongst the incompetent elderly’s loved ones as to what medical preferences to be applied in the end-of-life care that can only effectively dealt with the documentation in the ACP program.
ACP generally include the following “an ongoing discussion process on the patient’s end-of-life care wishes, appointment of a substitute decision-make incase the elderly patient becomes incompetent and finally explicit statement of the patient’s preferences for the sake of clarification when they finally become incompetent.” Thus, it is clear that for an ACP program to be effective, a patient’s medical history and conditions as well as their values, beliefs, preferences, perceptions and personal as well as family resource-base must be taken into account.
Taking into account all this considerations and engaging the elderly in decision-making process has been known to save loved ones resources as uncalled-for medical treatment is eliminated from the patient’s end of life care services. This also ensures that the patient can make informed decisions on their end-of-life preferences assisted by the doctors henceforth safeguarding their autonomy dignity and right to make informed decisions. ACP discussion programs are different from country to country based on the legislative framework within the specific country in question. Some of the ACP documentations include DNR (Do Not Resuscitate) orders, DNS (Do Not Hospitalize) orders, ACDs (Advance Care Directives) and SoC (Statements of Choice). It is important to note that these initiatives must have a legal backing and must be incorporated into the principles, culture and practices of the healthcare system.
Thus, for ACP to become part and parcel of the Healthcare as well as social care programs, decisions must be made in anticipation for worst case scenarios. For this to be possible, it means that information must be availed to the patient concerning the viable alternatives they have at their disposal at first contact with the health care providers or the social services providers. This implies that an effective ACP process begins when the patient is well and in a frame of mind to make objective decisions before dementia kicks in or the illness advances. ACP plans should always be reviewed based on the patient’s change in health conditions. This might include either health deterioration or emergence of new health issues of concern. Considerations must be made accordingly whenever the patient health status changes. To conclude it must be mentioned that ACP plans and programs only come in handy whenever a patient’s competency levels are questionable or there exists dissenting opinions on the best end of life strategies to be implemented.
References
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Nay, R., & Garratt, S. (2009). Older People: Issues and Innovations in Care 3rd edition. In D. Fetherstonhaugh, A. Street, & J. Abbey, End-Of-Life Decision-Making For The Older People (pp. 322-334). Chatswood, NSW: Elsevier.
