Older Patients In The Health Care System
In the world of medicine, older people are routinely treated differently than younger people. Older patients tend to receive less aggressive medical treatment than younger patients with the same symptoms. A 1996 study, for example, found that older women are less likely to receive radiation and chemotherapy after breast cancer surgery, even though they are more likely than younger women to die from the disease. In 1997 the U.S. General Accounting Office reported to Congress that most of the Medicare beneficiaries diagnosed with diabetes are not receiving the recommended blood tests, physical exams, and other screening services to monitor the disease. Although anticlotting therapy has been shown to reduce the risk of death among heart attack patients, older patients are less likely than younger patients to receive this treatment. Patients over age seventy-five are more likely than younger patients with the same severity of illness to have donot-resuscitate orders in intensive care units. Older patients are also undertreated for mental health services, preventive care, rehabilitative services, and primary care.
Several factors contribute to the discrimination older people face in the health care system. First, many health professionals adhere to the traditional view of aging as a continual process of decline. Unaware of the distinction between processes of normal aging and disease, they frequently dismiss older patients' complaints and symptoms. Physicians, for example, may write off older adults' symptoms of depression as part of the normal aging process and therefore fail to refer them for psychiatric assessments. Furthermore, doctors often prefer using their skills to cure acute illnesses rather than managing chronic diseases and rehabilitation. Because chronic conditions are much more common among the old than the young, physicians trained to focus on discrete causes of diseases and their cures may ignore the opportunity to intervene and improve older patients' quality of life.
Robert Butler has criticized the medical profession for not investing more research into the chronic diseases of older persons. Chronic conditions that slowly and permanently reduce older people's physical functioning may be less spectacular than acute conditions, but they are more far-reaching than the diseases that have been more intensively researched. Older adults have been poorly represented in other medical research and funding priorities as well. Few research studies, for example, definitively show that specific treatments are beneficial to older patients. Without the empirical evidence of treatments' effectiveness on older adults, physicians may not prescribe certain interventions.
Poor communication between patient and doctor is another contributor to the undertreatment of older adults. Research has shown that doctors are more responsive, egalitarian, patient, respectful, and optimistic with younger patients than with older patients. Communication problems also arise because older patients are more likely to be passive and accept their physicians' diagnoses without question.
Finally, educational institutions contribute to biases against older people in the health care system. Although treating the elderly, especially the very old, can be remarkably different from treating younger patients, medical students are rarely trained to handle the multiple and complex medical problems of older adults. One study, for example, found that the average physician's knowledge of aging was equivalent to that of college undergraduates (West and Levy). As a result, there is a critical shortage of geriatricians, or doctors specially trained to deal with older adults' unique health problems. Further, textbooks that focus almost exclusively on problems of aging and underreport successes expose students to narrow views of the aging process.
The aging of the population will likely compound these problems in the coming decades as the numbers of people needing acute and long-term care increase dramatically. Older Americans comprise less than 13 percent of the U.S. population but account for about one-third of health care expenditures every year. One of the central questions facing the United States is how the health care system will handle a growing elderly population. One proposal addressing this challenge would limit health care provided to people above a certain age. Philosopher Daniel Callahan, for example, argued in his controversial 1987 book Setting Limits that the very old should not receive expensive health care services. Former Colorado governor Richard Lamm went even further in his oft-quoted statement that older persons "have a duty to die and get out of the way." Although few Americans would withhold health care to someone solely on the basis of age, there are many supporters of preferentially allocating medical services to younger patients. They view health care as a limited resource that must be allocated to achieve the greatest good for the greatest number of people. Proponents of age-based rationing argue that chronological age is an ethical, objective, and cost-effective criterion for allocating health care because older people have already enjoyed life and have less life to enjoy. The greatest challenge to age-based rationing of health care, however, is that there is no necessary correlation between age and physical health. Everyone does not age at the same rate, making age-based rationing of health care a prime example of discrimination against older adults.
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