1. Healthcare Inequalities in the Elderly: Ethics and Quality Improvement John R. Stone, MD, PhD Center for Health Policy and Ethics Creighton University Medical Center

2. Conflicts of Interest None known

3. Learning Objectives Explain evidence & racial/ethnic issues Describe an ethical framework Explain implications

4. Case 1: CML Probability of being offered full spectrum of effective drugs –@ 75 versus @ 50 Stone 2012, Cambridge Quarterly of Healthcare Ethics

5. Case 2: In Rehab 80, depressed or sometimes irritable Rehabilitation professional –Regard as positive as at 45? Stone 2012, Cambridge Quarterly of Healthcare Ethics

6. Case 3: 65 Breast Ca_AA Woman Excisional biopsy Breast tissue conservation Radiotherapy –Same % advice as if White? Stone 2012, Cambridge Quarterly of Healthcare Ethics

7. Case 4: Rheumatology “Aggressive” and “effective” care Same for older as for younger patients? Stone 2012, Cambridge Quarterly of Healthcare Ethics

8. Case 5-Chronic Disease At age 72, will treatment be as established by research as at age 50? Stone 2012, Cambridge Quarterly of Healthcare Ethics

9. Case 6: Institutional Excellent tertiary hospital Rigorous Quality Improvement (QI) QI includes age-related care? QI includes care per race/ethnicity? Stone 2012, Cambridge Quarterly of Healthcare Ethics

10. Evidence Status Need more studies Existing data and care quality –Bad to be elderly –Worse to be elderly + racial/ethnic minority Uncertain –(Probably) worse: elderly, racial/ethnic minority, poor

11. Withholding Care & Ethics Fair distribution among age groups Unfair: merely because a person is old –Christine Cassel: illegitimate “implicit rationing” Cassel 2005

12. If you’ve seen one 70 year-old… “No ailment should ever be written off as an "old age" ailment. Treating patients based on their age means you can miss very significant, treatable situations. …If you've seen one 70- year-old, you've seen one 70-year-old. Mark Lachs 2010

13. “Every patient is different, and I hate the way the health care system pigeonholes people based on a number, and it becomes more absurd as patients get to be 70, 80 and 90, with great variations in their functional ability.” Mark Lachs 2010

14. Elderly Ageism Bias, prejudice, discrimination, devaluation Negative attitudes, stereotypes: dependent, grumpy, lonely, rude, stubborn, socially inactive, frail noncontributors* Mistaken beliefs: asexual *Eymard & Douglas 2012

15. Causes: Elderly healthcare disparities Elderly ageism Education/training deficit –Knowledge –Skllls Insufficient Research Inadequate review

16. Causes: Elderly R/E Health Disparities Stereotypes Bias Discrimination Personal level Institutional level Policy level?

17. Moral Framework Respect for persons Justice Beneficence Nonmaleficence/do-no-harm Care Solidarity

18. Ethical Framework/Anchors Respect for Persons JusticeCare Beneficence Do-no-harm Solidarity

19. Respect for Persons Not just respect for autonomy Respect for Persons EmpowerListenHumilityEngage Culture bridging Recognize

20. Justice Fair application of respect for persons and other professional ethical values –Health/healthcare equity Remediation if unjust inequality or inequitable treatment

21. Beneficence/Nonmaleficence Advance the patients’ good Do no harm when avoidable Minimize harm In light of respect for persons and justice

22. Care Needs of particular others/personal Empathic/emotional connection Thoughtfulness/considerateness Focus on vulnerable/dependent Attention to quality/groups Stone 2012, Cambridge Quarterly of Healthcare Ethics

23. Solidarity Alignment/unity/fellowship Empathic bridging across distance Opposes them/us Focus: most disadvantaged Stone 2012, Cambridge Quarterly of Healthcare Ethics

24. Foci of Equal Quality Patients you see Institution System State/nation

25. Quality IntentOutcome

26. Race/Ethnicity Example “I treat everyone equally.” “I do not vary treatment quality with people’s race/ethnicity and so forth, but I attune to their individual needs.” “My system/institution does not do quality assessments regarding race/ethnicity or age group.”

27. Quality Improvement QI Indicator Outcome Assessment RemediationReassessment

28. Quality Improvement Age Race/ethnicity Other –Language –Gender –Socioeconomic status

29. Quality Improvement/Elderly & R/E* Evidence Ethical Framework Outcomes Departments Institution Departments Institution Community *Disparities Solutions Center.

30. Recommendations Improving Attitudes & Views Enhanced curricular content Simulations: “The Aging Game” and others Narrative reflection *Eymard & Douglas 2012

31. Recommendations: Direct Care Sites Open group inquiry/discussion Iterative group value assertion MMM: Mindful Mentoring & Modeling

32. Recommendations Individual clinician –Communicate, engage, connect, honor, empower –Care, empathize –Bridge cultural and age divides –Reflect (respect, justice, care, solidarity)

33. Recommendations Individual clinician –Mentor/model –Narrative reflection –Humility/self-critique

34. Recommendations Department/Division –Curricular content –Faculty development –Value clarification –Legitimize discussion

35. Recommendations Department/Division –Mentor/model –Promote QI –Promote elderly research

36. Recommendations Institution –Quality improvement –Community involvement –Department/Division inclusion –Elderly research

37. Higher Levels Policy review

38. References Cassel CK. (2005) Medicare Matters: What Geriatric Medicine Can Teach American Health Care. Berkeley: University of California Press. Disparities Solutions Center. Massachusetts General Hospital. Boston. (See several documents regarding healthcare disparities.) http://www2.massgeneral.org/disparitiessolutions/resources.html#imqual http://www2.massgeneral.org/disparitiessolutions/resources.html#imqual Eymard, A. S., & Douglas, D. H. (2012). Ageism among health care providers and interventions to improve their attitudes toward older adults: An integrative review. Journal of Gerontological Nursing, 38(5), 26-35. Mark Lachs 2010: “Ageism in Medicine: How It Appears, Why It Can Hurt You: Interview with gerontologist Mark Lachs.” Maureen Mackey. AARP Bulletin. November 18, 2010. http://www.aarp.org/entertainment/books/info-11- 2010/author_speaks_ageism_in_medicine.html (04Aug2012) http://www.aarp.org/entertainment/books/info-11- 2010/author_speaks_ageism_in_medicine.html Powers, Madison; Faden, Ruth. (2006) Social Justice: The Moral Foundations of Public Health and Health Policy. New York: Oxford Univ. Press. Stone JR. (2012). Elderly & Older Racial/Ethnic Minority Healthcare Inequalities: Care, Solidarity, and Action. Cambridge Quarterly of Healthcare Ethics. 21(3), 342-352. Stone, JR. (2012) Healthcare Inequalities in the Elderly. Ethical Times. Bulletin of the Program in Medicine & Human Values. California Pacific Medical Center. Sutter Health. 29(Spring), 1, 4-5.