In a new book, a public health expert explores the ethical ramifications of providing care to older adults discharged to their families

Caring for Older People in an Aging Society

Rutgers University
6/27/17

"What are the cases that keep you up at night, the ones in which you are unsure what you should do?” This was the question Michael Gusmano, associate professor of Health Policy in the Rutgers University School of Public Health, and his colleagues from the National University of Singapore, the Hastings Center and the University of Oxford posed to more than 180 Singapore professionals who care for the elderly, including doctors, nurses, social workers and nursing home and adult day care center administrators.

Their answers resulted in Caring for Older People in an Ageing Society, an online casebook published by the Centre for Biomedical Ethics at the National University of Singapore, which contains 10 fictionalized scenarios supported by expert commentaries highlighting the ethical issues presented and giving practical insight.

Gusmano, a co-editor and co-author for the book, says that although the case studies are based in Singapore, the themes are universal for anyone caring for aging adults and navigating the often-ambiguous situations that arise.

Rutgers Today spoke with Gusmano about the top concerns of providing care in a world with an increasingly aging population and how providers struggle with knowing when lines should be crossed.

How are the scenarios in this casebook applicable to care providers in the United States?

Singapore, like the United States, is aging rapidly. People are living with chronic, progressive illnesses, and much of their care occurs outside of hospitals. If families and social support systems are not properly equipped, these people are likely to bounce back and forth to the hospital. The pressing questions for health care and social care providers are: to what extent do you understand the values of your patient who is resisting a care plan and how much do you intervene?

We published the case book online and with open access book so that care providers can open up conversations about these issues.

Discuss the importance of having a strong social and community care system.

If you do not have the right infrastructure for care in the community, it can undermine the investment in a health care system in which time matters and there is pressure to clear beds. In the United States, when you look at the economic value of informal caregiving by family members and friends it swamps how much we spend on Medicare and Medicaid combined. The rise of age and chronic illness coupled with this desire to save money on inpatient stays means there is an increasing reliance on informal caregivers. Thus, we are making more demands on the sandwich generation – primarily women caring both for their parents and their children. Societies need to rethink how they can support this important family caregiver role, because we do not have backup systems for this kind of care.

What are some of the biggest challenges health care providers cited?

Although technology now allows hospitals to send people home with medical equipment, that equipment often needs constant monitoring. This creates additional burdens at home and can result in hospital readmissions.

Professionals in Singapore struggle with how to balance this need to clear hospital beds and the patients’ desire live independently with a realistic plan for what family members can manage in terms of bathing, dressing and lifting their loved ones and managing medical technology. We don’t want to keep people in expensive institutions longer than they need to be there, but returning home is difficult for people living with multiple chronic illnesses and often limited mobility.

What are some scenarios that are discussed?

The book highlights the challenges faced by people who interact with the older people in a variety of ways: A medical team analyzes what they should do after man who has suffered a stroke repeatedly returns to the hospital after his home care plan falls apart; a father of a teenage son ponders his duty to take his parents into his home to live when his ailing father can no longer care for his mother who is suffering from dementia; an aging caregiver of a mentally disabled adult child is anxious about what will happen to him when she dies. We want to help professionals reason through these situations and consider the values at stake to make ethically defensible decisions.

How can looking at Singapore help U.S. providers prepare for the future of health care here?

In Singapore, longevity rates are high and birth rates are low. The country is rapidly going from one of the younger countries in the world to one of the oldest. The United States is much younger, but we are moving in that direction quickly. By 2030, it’s expected that 20 percent of our population will be 65 and older – and the fastest-growing segment of the population will be over 85. While this is a reflection of successes in health care, it brings new challenges. If people can’t live independently and we don’t want to warehouse them expensively in nursing homes, we need to rethink systems of care that make it possible for people to live safely and fruitfully in communities. The systems we are inadequate to meet the coming challenge.