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Healthcare for the elderly

R.Sundaram
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Doctors are not always to blame.
Doctors are not always to blame.

An article on doctors’ negligence towards the elderly, ( Business Line, July 15) — rendering a gist of the recent reports on the care of elderly in hospitals in the UK — expressed concern about similar indifferent treatment meted out to the elderly in our country.

Unlike the UK, we are grappling with infant mortality, maternal mortality, child malnutrition, stunted growth, et al, even as there is undoubtedly an accretion in the population of the aged. Hard facts, such as 1.25 million child deaths yearly and 42 per cent of children being undernourished obviously will determine our priorities.

Criticism about treatment of a particular demographic segment of the population has to be considered in the specific socio-cultural settings of the countries concerned. The UK, through its publicly funded NHS (National Health Services), over decades, has built a highly standardised care for all its citizens.

On the other hand, in India, there is a great gulf between the quality of care received by the well-off, and the poor. In the UK, NHS is a national obsession and each aspect of its working — and therefore its shortcomings — is a matter of daily debate in the media, TV, radio and print. It would be highly depressing and scary, and nobody may go to hospitals in India if a similar intense scrutiny is carried out here in full media glare.

Objective & subjective

Good healthcare in a hospital setting comprises an objective treatment procedure and a subjective experience by the patients and their relatives.

More often, the patients take the treatment procedure for granted but find their subjective experience less than satisfactory. For the first the doctors are responsible, and for the latter the nurses, ward boys, paramedics and numerous others, including the accountant.

But the critics of any health system often seem to turn their ire mainly at the doctors. Caring, particularly of elders, necessitates more attention on the part of nurses, ward boys and so on.

But hospitals, which will not hesitate to hire foreign-trained doctors for huge salaries, will cut corners when it comes to staffing at the level of paramedics. If there are only two nurses for a 30-bed ward, and simultaneously if there is a 30-year-old calling for the nurse and an eighty-year-old-moaning, it is more than likely the former will be attended to first. Like it or not, this is an intuitive human response.

Age factors

Healthcare is also not about performing heroic surgery on every 90-year-old, but taking an informed decision and giving patients an opportunity to make choices. It has been well-recognised that age is an independent risk factor for mortality in ‘surgical, prognostic models or scoring systems’.

With advancing age, there appears to be a degree of chronic impairment which impacts predictions of mortality.

What is more disconcerting is that after such treatment, the survivors do not return to their previous functional status and are often plagued with neuro-cognitive disability, poor mobility and more dependency on their families. Of course, the elderly should be treated with dignity and respect. Health is not a matter of “the absence of disease or infirmity” but “a state of complete physical, mental and social well-being”.

The two guiding principles that influence the decision-making of most physicians are non-maleficence and beneficence. In other words, one has to do the right thing by the patient without exposing him/her to undue risk, discomfort or pain if one is not convinced of the overall benefit.

The physician often makes the decision based on the severity of the illness, levels of frailty, the expected impact of the treatment on outcome and the patients and/or their family’s expectations.

(This article was published in the Business Line print edition dated July 28, 2012)
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