Autonomy in Long-Term Care

            The determination of the amount of autonomy a person should have is the root of many ethical problems in long-term care.  Patients wish to make their own decisions regarding care they receive in order to feel self-worth and respect, but there is difficulty determining who should make the decisions of futile care: the patient or the provider (Pratt, 2009, p. 328).    While it is fairly common in the long-term care spectrum for patients be incompetent, and therefore, unable to make decisions about their treatment, competency is still very challenging to determine, due to the fact that some patients may be able to make one decision but not others.  This decision is usually made in court, but there are no definite means for determining the competency of the patient because it is a personal judgment (Pratt, 2009, p. 334).

            Long-term care consumers may avoid this unpleasant situation by creating an advance directive to state their wishes when they are fully competent and able to make decisions prior to needing immediate medical care.              While living wills can help to communicate the wishes of the patient of which treatments they wish or do not wish to receive, advance directives are not always recognized by the law, so they do not always ensure these wishes will be carried out, due to the fact that family members can challenge the legality of the document (Pratt, 2009, p. 337). 

            In the case of futile care, a patient can receive care beyond their wishes stated in a living will due to the fact that the facility is not aware of their advance directive, or this care is necessary based on the transfer arrangements from acute care to long-term care or from one institution to another due to the fact that providers are obligated to treat unless told otherwise (Pratt, 2009, p. 340).  These situations directly relate to the debate regarding should the patient or the provider determine the use of futile care, and in both cases, neither the patient nor the provider is solely making the choice.  Ethically, the patient should make all decisions regarding the care they wish to receive, however, if they are deemed incompetent and do not have an advance directive, the provider should have a responsibility to advise the family members, but not to make the decision for the patient.          

Elements of an Ideal System

            The first and most important factor in achieving an ideal healthcare system is creating a market that is consumer-driven:  “Availability and utilization of long-term care services should be based on the needs of the consumers of those services, rather than on the needs of providers, reimbursement agencies, or politicians” (Pratt, 2009, p. 37).  This ideal is nearly impossible to achieve in the current healthcare market place; however, it could be realized in some form under a healthcare reform that would encourage true competition among providers and little government involvement.  In this scenario, healthcare would be similar to purchasing any other goods or services. 

            Another important aspect of an ideal system would be focusing on customer needs and rights.  Each customer needs to be recognized as an individual and be treated with courtesy.  In the past, many long-term care institutions had a less than positive image in the public eye, but that would spell disaster in an idyllic system because the healthcare market’s success would depend solely on consumer approval.  By recognizing each customer’s needs, wants, and cultural values, healthcare employees can show empathy and caring to those they care for, and in return, consumers will value these services by feeling they are treated with dignity and respect.

            In addition to the healthcare system’s needed commitment to its consumers, everyone will, at some point in their life, need healthcare services, so they should do their part to help keep costs low for everyone by making good lifestyle choices.  The long-term care portion of the healthcare system is particularly affected by personal choices such as smoking, over-eating, excessive use of alcohol, recreational drugs, etc., due to the fact that over time they cause many serious health problems, leading these consumers to need institutional care for the remainder of their lives.  This could be avoided, or at least prolonged, in most cases if as a whole our country practiced healthy behaviors, thus saving money for everyone and improving the quality for life for the many. 

            There is a great need for a healthcare system that is simple to use, understand, and transfer throughout with ease.  Particularly in the long-term care realm, elderly users can have difficulty entering into the system due to the numerous providers and facilities they would need to use.  There is also the problem of financing and approval processes needing to be simplified and coordinated (Pratt, 2009, p. 44).  All of these difficulties can cause a delay in services and treatments and do not meet the criteria of an ideal system.  The “aging in place” programs that are being adopted by numerous organizations are a step in the right direction to fixing this complicated system because they allow patients to receive multiple levels of care in only one location (Pratt, 2009, p. 44). 

            Funding for healthcare is another important topic when it comes to creating an ideal system, however, there is no simple answer to this problem.  With the current debate on this topic, it is understandable that there is no clear solution, and looking at other countries’ healthcare systems, it is probable that there never will be a system that works perfectly.  With this in mind, however, there is a great deal that can be improved here, especially by eliminating medical bankruptcy, which is virtually unknown in other developed countries.  A possible solution to this would be to create a system in which insurance is obtained entirely through the private market with no employment necessary.  Also, everyone should be paying into the system and be covered by their plan of choice.  

Ethical Dilemmas in the Future of Health Care

While the future of health care is very uncertain at this time, there are several predictions about the changes that will come and trends this industry will potentially see in years to come.  Regardless of the extent of government involvement in health care, several changes in the system will occur, which includes a growing elderly population that is more culturally diverse, increase in chronic conditions, and more emphasis being placed on the consumer.  As technology advances, new medicines and vaccines are created, and other innovations are developed, the majority of Americans will be leading longer, healthier lives.  Also, with the prospect of immigration continuing at an extraordinary rate, the country and long-term care population will become increasingly more diverse and require the industry to focus more on the individual customer’s needs if they want to recruit and keep customers.  Furthermore, future customers will demand more choices, and they will be more informed, which will allow them to choose how they spend their money on health care.  Resulting from this will be many improvements in the industry including fewer unnecessary procedures because patients will be managing their medical expenses more efficiently, and the quality of care will increase to persuade customers to choose one institution over another when competition increases. 

With all the changes and innovations to come, there will be an explosion of new ethical dilemmas.  Currently, there are a number of these problems that cannot be solved due to differing values among Americans and politicians.  In the future, this will only increase as new inventions produce new questions about ethics in health care.  Possibilities include cloning of humans, artificially prolonging or ending life, radical surgeries and procedures, growing organs and other body parts, and other discoveries that will challenge religious beliefs or ethical principles.  As the need of health care services intensifies with a growing population seeking care, the limited number of resources will have to be distributed, and this will also lead to more ethical issues.  Choosing who is more deserving of a procedure or of a doctor’s care will be very difficult, and there will never be a consensus among all Americans.  With the great expense that is associated with long-term care, there may be debates about how many people the government can afford to cover under Medicare and the types of services patients may have to fund themselves.  Also, there may be restrictions placed on certain types of care or surgeries if a person is in a condition due to poor personal choices, such as abusing alcohol or drugs or becoming obese due to an unhealthy diet and little exercise.   These and many other restrictions could cause many people not to be covered for a life-saving surgery or to have their long-term care paid for by the government, but it raises important ethical questions without one specific answer.  Should procedures or care be denied to patients who smoked in the time period before there was conclusive evidence that cigarettes lead to cancer and other medical conditions?  Will the same surgery be approved for one person but not for someone else if there are limited resources?  Will the elderly be denied procedures if younger people also are in need due to limited government funds?  Will health care premiums rise for those with a history of smoking, drug use, alcohol abuse, or obesity?  Should the government cover all individuals who are eligible to receive Medicare or Medicaid if they made the same poor personal choices as those being punished for the same thing using private insurance companies?

Many of these questions would be very difficult, if not impossible, to answer and agree upon.  In the future, health care costs will undoubtedly rise and resources will become less available with more and more people in need of medical care, particularly long-term.  It is very important that the citizens of today, along with the government, begin to plan for tomorrow’s problems and ethical dilemmas in the present if we want to have a chance to solve them in the future. 

Thursday, August 27, 2009

 

Long-Term Care

 

            Long-term care encompasses several different sections of the broad health care field and involves caring for people of all ages who need assistance for an extended period of time.  Many times this care would continue throughout the remainder of the patient’s life, and the level of physical or mental shortcomings of the individual would determine the type and duration of nursing needed.  While it is a common belief that only the elderly are recipients of long-term care, there are also adults and children who utilize the same type of care due to handicaps. 

            I recently had some experience in this area when my eighty-six year old grandfather became very ill and began hallucinating.  Until that time, he had been living independently, but in view of the circumstances, my family and I investigated several different long-term care options, such as nursing homes, assisted living, and home health care.  There are a vast amount of options available to those seeking long-term care, and this creates a great deal of competition in the industry, which then leads to a staggering expense for those in need of assistance for an extended period of time.

            I also had the experience of helping patients who would need long-term care after they were released from South Lake Hospital when I volunteered there.  The majority of them would never be able to live on their own again due to the chronic conditions they suffered from.  This occurrence led me to become interested in the health care field in general, as well as possibly working in a long-term care facility to ensure that those with life-long illnesses and disabilities are cared for properly and are able to enjoy their life to the fullest extent possible.