What Matters in the End
By Michael Wong
“You may not control life’s circumstances, but getting to be the author of your life means getting to control what you do with them.” — Atul Gawande [1]
When the topic of mortality arises, society often strays away from thinking about the inevitable: how will we live out our last few days, weeks, months, or even years. Mortality is something that we cannot pinpoint, so many choose to ignore it. However, as we grow old, our perspective changes; people realize life has flown by, the drive for new begins to fade, and many instead look to maximize what they already have around them.
As we know, with old age comes deteriorating health. To support the ones we love, medicine has become particularly advanced in lengthening and strengthening peoples’ lives. Life expectancy was “under 50 in 1900, climbed to more than 60 by the 1930s, and today, it is in the late 70s in the United States,” all thanks to vast improvements in medicine. [2] However, this continuous progress has simultaneously created new problems surrounding peoples’ ability to live out satisfying lives in their old age. With the creation of medical care facilities such as retirement and nursing homes, these infrastructures fall short of creating a more meaningful and financially sustainable life for the elderly, instead merely prolonging their lives without much thought for their well-being.
The Demand and Importance of Geriatricians
While the elderly population is consistently growing, the number of geriatricians (physicians who handle the care of elderly people specifically) is extremely outnumbered. According to the AGS, although there is a slight growth in the number of projected geriatricians, there is a steeper 45% increase in demand for geriatricians between 2013 and 2025. [3]
This small growth stems from the fact that geriatrics is among the lowest-paying specialties in medicine despite the extra year or two of training beyond that of a general internist. [4] Paradoxically, geriatricians undergo an annual pay cut of approximately $20,000 from dedicating their time to gaining more expertise.
Geriatricians hold a unique and immensely important perspective when compared to other physicians’ treatment.
“Most doctors treat disease and figure that the rest will take care of itself. And if it doesn’t — if a patient is becoming infirm and heading toward a nursing home — well, that isn’t really a medical problem, is it?
To a geriatrician, though, it is a medical problem. People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable and to avert at least some of the worst effects.” [1]
The job of any doctor is to support quality of life through two themes: cultivating as much freedom from the ravages of disease as possible and ensuring the retention of enough function for active engagement in the world. [1] When doctors utilize the solution of nursing homes to follow up the shortcomings of their proposed treatments, they are providing fighting power against the ravages of disease, but strip the elderly of their active engagement within the world. Since many doctors are not properly trained in these perspectives due to the rarity of these types of encounters outside geriatrics, the active engagement of many elderly are shortened at the fault of improper judgment. This is exactly why geriatricians are vital to a thriving elderly society as they are necessary to overhaul this type of care.
To approach this extensive issue, two assets of reform should be enacted. First, there must be a greater incentivized salary to attract more geriatric experts; further expertise and training that boosts patient well-being should not result in decreased pay. Second, to transform the perspective of elderly treatment, existing geriatricians should train primary care doctors in caring for the very old, preventing the use of nursing homes as the easy way out. [1]
Reform of Medical Care Facilities
When independence is no longer possible, numerous options open up usually for the family to decide, some more appealing than others. Families might consider the option of taking care of their elderly themselves while others might consider alternatives such as assisted living or even the notorious nursing homes. However, each option weighs heavily on the future of their loved ones, so the choice is never easy.
As the elderly have usually adjusted to living independently for years, this sudden change can be extremely discomforting both mentally and physically. Therefore, many families may feel that their home is the best environment for their elderly to thrive and adjust to. Without understanding how demanding this might be, this generally sounds like a good idea to avoid nursing homes. However, with old age comes lots of potential health hazards that require demanding attendance, often taking an enormous burden on families that are already occupied with their daily lives. In a study comparing the outcomes of at-home care to nursing home care, shifts in long-term care for older adults moving from nursing homes to home- and community-based long term care, while well-motivated, resulted in substantially higher hospitalization rates. [5] Although the elderly may be more satisfied by surrounding themselves with loved ones and having more opportunity to pursue interests, it is important to weigh and consider the ramifications of increased nonattendance and lack of expertise when compared to alternative care.
When the option of a nursing home is inevitable or preferred, we must consider the origin of purpose for these institutions as they shine light on their current practice. Initially, nursing homes were meant to ease hospitals’ burden and provide better care for the elderly, but as the institutions have evolved, they have fallen short of this goal. [6] As hospital beds initially filled up, lawmakers provided funding to help hospitals build separate units for patients needing an extended period of recovery, what we now know as the modern nursing home. Therefore, the systems devised for the elderly are inadequate because they are nearly designed to solve infrastructural problems (i.e. hospital overcrowding) rather than taking into account the elderly’s needs. Activists such as Atul Gawande suggest that nursing homes require immense reform, going from more than simply a place to live and receive basic care to a place that is financially sustainable, technologically possible, and psychologically meaningful. [1]
A medium that could achieve both the independence and commendable care of the elderly was a vision sought out by Rosalie A. Kane through her project of assisted living. [7] Through this medium, the elderly could maintain their own livable space, adding touches of identity that were maintained unlike the dull rooms of nursery homes. Here, they would have the freedom to continue on with their daily routines, having adequate professionals on stand-by in the case of any medical emergency/assistance. As an initial start-up, this vision was a success, filling to maximum capacity with an astounding waitlist. [1] The elderly felt as if they could live out their lives with purpose, preserving parts of their identities that would have nevertheless been overlooked by survival over well-being. However, the success attracted the eyes of an industry looking to profit off their own assisted living facilities. Through variations outside of Kane’s goal, new assisted living facilities focused on maximizing profit over elderly satisfaction. With more and more of these money-making chains, Kane’s vision spiraled downward, eventually routing back to the same existent nursing homes.
Taking a step forward in the future, Kane’s goal of balancing elderly satisfaction with adequate treatment was superb, but eventually exploited by those seeking to make profit. With this attempt in history, nursery homes have a basis to reform, knowing what potential mindsets or decisions might jeopardize meaningful change. However, before reaching the state of fallen independence, it is important to remember this perspective.
“A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.” [1]
Sources
[1] Being Mortal: Medicine and What Matters in the End (Gawande, Atul)
[2] Life expectancy (from birth) in the United States, from 1860 to 2020 (Statista)
[3] State of the Geriatrician Workforce (AGS)
[4] As Population Ages, Where Are the Geriatricians? (New York Times, Katie Hafner)
[5] Is Being Home Good for Your Health? Outcomes of Medicaid Home‐ and Community‐Based Long‐Term Care Relative to Nursing Home Care (R. Tamara Konetzka, D. Jung, R. Gorges, and P. Sanghavi)
[6] How’d We Get Here? The History of Nursing Homes (Birnstengel, Grace)
[7] Remembering Rosalie A. Kane. (Degenholtz, Howard B.; Wilson, Keren Brown; Polivka, Larry; Reinhard, Susan C.)
Michael Wong is a 2nd year MIMG student at UCLA and is a THINQ 2021–2022 clinical fellow.
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