Touchy Subjects
In addition to making the best use of human (ie, clinician) resources, the US needs to face some of the tough ethical questions that arise when you must balance respect for the lives and health of older adults with a shrinking economy and limited funding.
“We definitely undervalue [older adults’] health care, because if you look at where we put our money, we put it into preserving the young person,” Bakerjian says. “We’ll put inordinate amounts of money into doing specialty procedures for young people, but we won’t put at least an equal weight [on] doing basic primary care and good comprehensive coordination of care for older adults.”
At the same time, “We are not going to be able to continue to pay for every woman in her 80s or 90s to have a mammogram, which is going to show something and then we start a million-dollar work-up that may or may not come to anything,” Resnick says, adding, “I’m not saying we should stop, but I think those are the types of issues we need to deal with.”
Even preventive measures such as vaccination may need to be reconsidered if supplies are insufficient or in the event of a pandemic. Recent research suggests that older adults’ immune systems do not respond as well to vaccination as children’s do. While vaccinating persons at high risk for death from infection makes sense, overall, Resnick says, “If we had more children who had less infections and didn’t expose older adults, we’d be better off.”
But by far, the “touchiest” questions relate to end-of-life care and dying. Segal-Gidan, who works predominantly with persons with dementing illnesses at the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center, knows from experience that most patients would rather not die in the hospital, and many do not want aggressive end-of-life care.
“A significant body of literature shows that there’s a lot of money spent in the medical system on people in their last days and months of life that is essentially wasted, because it’s spent in hospitals and intensive care units,” she says, “whereas, if there had been discussion with patients and their families months and years previously, they would be home in hospice care. That’s what people want.”
Can Americans come to terms with their squeamish attitudes toward death? If they are going to, clinicians must learn to overcome their own reluctance to speak about uncomfortable topics—just as they have in the past.
“If we talk about trying to change curricula and training, people should be trained to have a level of comfort in talking about death and dying the way they talk about sex,” Segal-Gidan says. “People don’t have any problems, in the last 10 years, in talking about sexual activity with men who are in their 60s and 70s and then prescribing Viagra.”