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.