Executive Summary
As the baby boomers age, case managers will need to learn more about how this large senior citizen demographic shift will affect healthcare management and services, including end-of-life services.
- It’s important to respect elderly patients’ autonomy while encouraging them to outline what their healthcare preferences are in the event they are incapable of expressing their desires during a health crisis.
- Case managers can encourage patients to write advance directives that their family members can refer to when needed.
- Case managers might also educate elderly and very ill patients about surrogate decision-making and Physicians Orders for Life-Sustaining Treatment.
The aging baby boomer population has led to the largest growth in seniors in history, pushing total numbers of people age 65 and older to more than 40 million in the United States. Within the next 15 years, senior citizens will account for about 20% of the U.S. population.1
This demographic shift is creating the need for case managers who specialize in geriatric or senior care, or who at least are aware of end-of-life ethical issues involving older populations, including respect for autonomy.
“What respect for autonomy is, and I think people forget this, is a more active approach than letting people do what they want,” says Douglas P. Olsen, PhD, RN, an associate professor in the college of nursing and an adjunct associate professor in the college of human medicine at Michigan State University in East Lansing. Olsen also is a contributing editor to the American Journal of Nursing and an associate editor in Nursing Ethics. He has spoken at case management conferences on the topic of ethical decision-making in elder care.
The idea of enhancing autonomy in healthcare is to let patients increase their own ability to make decisions and extending their autonomy through advance directives, Olsen explains.
“The key ethical issue that comes up in a lot of cases is decision-making capacity in the elderly population,” Olsen says.
For instance, a case manager can facilitate the opportunities for patients to make an advance directive and monitor patients to see if their capacity is declining, he adds.
“If there are decisions patients are no longer able to make in their own best interest, then we need to make sure they’ve identified a surrogate decision-maker so the person they want is the person making the decisions,” Olsen says.
Determining decision-making capacity is difficult conceptually and a critical assessment, and yet there are no educational standards for doing it, he notes.
“Case managers can identify whether there’s a need for an assessment or an additional assessment, which usually is a doctor, but there is no mandated training,” Olsen says. “People who are not making decisions in their own best interest are people we have to protect.”
Olsen offers the following examples of instances when case managers can facilitate more ethical elder care:
• Advance directives: “I think a case manager could identify the need for an advance directive conversation, arrange for the person to have an advance directive, and have an understanding of what decision-making capacity is,” Olsen says. “Advance directive goes into effect when you lose decision-making capacity.”
Any healthcare professional, including case managers, who are working with older — or even younger — patients should ask them to think about advance directives before they are seriously ill, he recommends. “Be direct and ask people, ‘Do you have a document that will help your family decide — if you are ill and are no longer able to decide for yourself — what medical care you’ll receive?’”
If someone is injured or ill and is in a coma, it’s very hard for family members to know what to do. An advance directive signed by the patient at least gives their loved ones some idea of what they wanted when they were healthy and able to make an informed decision, he adds.
Case managers can facilitate advance directive decision-making by asking patients if they have an advance directive, and giving them tips on how to find a good one, Olsen says.
“People don’t really know what it means to be in an intensive care unit, so you can give them ideas about what would make this advance directive a better document,” he says.
For instance, the case manager can ask patients these questions:
- What do you think it means to be on a respirator?
- What does it mean to have a feeding tube?
- If someone is in a vegetative state, what is their real chance of recovery?
- What can happen to people who are frail and older and given CPR?
“People should have a good idea that, even when CPR works, if the person is already seriously ill it doesn’t work for long,” Olsen says. “A lot of people die within five days of successful CPR, and CPR can do a lot of damage itself: You can live, but have your functioning seriously damaged, including brain damage.”
These are questions that every person should think about as they make a decision about advance directives, he says.
The main goal of an advance directive is for people to think about what might happen if they are incapacitated through illness or injury and to share with their families their thoughts on what should be done, Olsen says. “Autonomy is all about knowing what you’re getting into.”
• Surrogate decision-makers: Case managers also can encourage elderly patients to designate a surrogate decision-maker in the event of an accident or illness that renders the patient incapable of making a healthcare decision.
This surrogate decision-making authority can be legally formalized with a power of attorney or living will.
“It works best if the person identifies a surrogate decision-maker and then talks with this person about it, saying, ‘This is the way I feel about the goals of healthcare; these are the kinds of things I would want,’” Olsen says. “Surrogate decision-making is more about knowing how the person thinks about things because it’s hard to anticipate every healthcare parameter.”
Patients need to think about who would be a good surrogate decision-maker. As several prominent national coma cases have shown, it’s tragic when family members disagree about what type of treatment an incapacitated patient might have wanted, he says.
If a patient hasn’t outlined his or her wishes in an advance directive or appointed a surrogate decision-maker, then doctors often will go along with the wishes of the person who is the most forceful, Olsen notes.
“The daughter takes care of the mother and they had a close relationship, and then the son, who’s a lawyer, flies in and wants something different?” he says. “Who does the medical team listen to?”
Even in cases where the patient signed an advance directive, this could be ignored if a family member is forceful enough in pushing for life-sustaining procedures. But a surrogate decision-maker overrides the emotional decisions of others involved with the patient.
Case managers might even suggest that patients consider having a secondary surrogate in case the first surrogate is also unable to make decisions. This is an important follow-up step in the cases where the surrogate decision-maker is a spouse who also is elderly. The secondary surrogate decision-maker could be an adult child, Olsen suggests.
• Physician Orders for Life-Sustaining Treatment (POLST): POLST forms complement advance directives and are typically suggested for anyone with a serious illness. They provide medical orders for current treatment and guide actions by emergency medical personnel, as well as guiding inpatient treatment, according to the POLST.org website.
“When a person is older and more ill, they can take the next step and get a POLST, which is a traveling doctor’s orders,” Olsen says.
If a very ill person collapses and an ambulance arrives, the POLST will say whether the person wants CPR performed. “Everyone can recognize the POLST,” Olsen notes.
The POLST is very helpful with end-of-life care decisions.
“In the end of life, we’re talking about treatments that have possible marginal benefits,” Olsen says. “There’s a lot of room for preference in what goes into what is a reasonable way to treat you; it’s one of those preference-sensitive situations.”
POLST is a way for people to extend their autonomy and to exert their preferences and decisions about how they will be treated, in advance. “It’s all about extending a person’s control over their treatment and having people respect their decisions,” Olsen adds.
REFERENCE
- Larsen D. A shortage of senior care management for aging baby boomers? Senior Living. Published online on May 22, 2013. http://bit.ly/1OiORpc.
As the baby boomers age, case managers will need to learn more about how this large senior citizen demographic shift will affect healthcare management and services, including end-of-life services.
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