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.