Review of Karen Hitchcock’s Quarterly Essay on Ageing.

“Ours is a society in which ageism, often disguised, threatens to turn the elderly into a ‘burden’ – difficult, expensive and homogeneous.”

In the March 2015 issue of the Quarterly Essay, Karen Hitchcock delves into the Australian healthcare system, making explicit something that, as she says, often remains unsaid and yet can be heard quite clearly: “That the elderly are burdensome, bankrupting, non-productive. That old age is not worth living.”

A physician at a Melbourne public hospital, Hitchcock masterfully writes this kaleidoscope of well researched references from publications such as The New Yorker, The ­Atlantic and The Age, powerful personal stories of elderly people who have been in intimate contact with the healthcare system, and her own insight into the broader societal and medical cultures that reinforce a failing system.

It is not just a prescriptive call for reform of the healthcare system, but a humanistic appeal for a change of our cultural view that youth is the only part of life worth living and protecting. It is a call for deep social transformation so that we can all have confidence that when we too become old, our society will provide us with care, respect, dignity and love.

If you have the time to read the full essay, I would highly recommend it. It is as tender as it is informative, as heartbreaking as it is inspiring. If you don’t, however, here are the key points that you need to know:

1. We are living longer than ever.

“This new longevity of ours is a triumph”. However, our Australian healthcare system and society are struggling to adapt to an aging population and the unique social and medical needs of the elderly.

2. We deny that we will ever be like them

Societally, there is a disconnect between the way we view me [a young individual] and them [the homogeneous old]. Outside of our own direct relatives, we seem to view elderly people as a different species of human unrelated in any way to their young selves. Like a kitten, or a baby, we often reference the elderly with “he’s so cute” or “she’s so adorable”.

In general, we do not see the elderly as actively valuable individual members of society, and instead we are fearful of the “swelling ranks of greedy geezers, the oncoming tsunami of the sick and frail elderly who will be an emotional and financial burden on their families and friends, and whose infirmities could bankrupt the healthcare system”.

3. Our doctors don’t want to treat them

Elderly patients are very often multi-morbid, meaning they suffer from multiple chronic illnesses at one time. Because of this, their medical needs are complicated and require a whole-of-body approach to treatment. With our healthcare system increasingly focusing on specialist areas (eg. Gynaecological oncology, Cardiology, Urology) elderly patients fall into the cracks between these fragmented specialties, the cracks widened by the reputational disincentive for medical students to become General Physicians.

In addition, there is an embedded ideology about the ‘futility’ of treating the elderly and a dominant narrative criticizing ‘excess treatment’ – both of which encourage a rationing of treatment for older people, a cost-benefit analysis of a human life. The end result of this: Doctors who compete not to deal with the elderly as they come into the emergency room and elderly patients who spend their valuable treatment and recovery time apologising to doctors “I don’t want to be a burden”, “I know I’m a nuisance”.

4. Our healthcare system fails them

Our hospitals are world-class and designed to be effective and efficient, but efficiency is not what elderly patients require. They require time and integration of multiple medical specialities to understand their complex medical needs and history, they require adjusted dosages of drugs to treat their interrelated ailments, they require someone to help feed them because often they are too weak to do so themselves, they require a human touch to keep their spirits high and they require at-home healthcare services that support their independence and keep them out of the hospital.

Currently hospitals require all elderly patients to complete a treatment plan outlining their future limitations on treatment. Intended to give patients choice and a ‘dignified death’, for doctors these plans often make it as simple as a check-box to put a patient on the ‘palliate path’. With the cultural weight of feeling like a burden, especially when asked to fill out the form at the hospital itself, elderly patients are at risk of self-depriving themselves of future treatment; with a healthcare system that allows it.

5. We don’t want to pay for their healthcare

“The elderly have been, and remain, the last priority in our medical system and the ones we target first with our austerity measures.” Of the world’s wealthiest nations, Australia spends among the least on health as a percentage of GDP – about half that of the United States. According to a recent report issued by the Australian Institute of Health and Welfare (AIHW) our spending on health is rising at a far slower rate than any time since the 1980’s, yet we now have the longest life expectancy in history.

For the sake of comparison: there is a stronger negative narrative around the cost of elderly care, compared to our willingness to pay for the treatment of increasingly poor, obese, diabetic, sedentary young and middle-ages who will require many drugs, doctors, operations and hospitalisations. It is often said by the government and other analysts that that the public medical system is ‘unsustainable’.  Stripping away the political jargon, sustainable is just a word for ‘what we are willing to pay’.

6. There is a better way

Currently, our healthcare system is reactive: responding to crisis, intervening too late, patching a patient up and shipping them off. Most crucially, medical needs and social needs are delivered in a fragmented way by separate organisations. But there is a better way. Two countries have lead the way in ensuring elderly care is proactive in integrating general physicians and specialists with community services and hospitals. And most importantly, giving the elderly the two things they consistently respond positively to: love and the opportunity for purpose.

Denmark: Denmark has prioritised preventing decline, responding early to health problems and supporting older citizens to care for themselves. To do this, they have set up 24 hour multidisciplinary centres with GP’s and specialists, nurses and allied health practitioners such as physiotherapists and social workers, established at the community level. Relationships are forged, care is individualised, and the need for hospitalisation is reduced.

Japan: Japan has the largest proportion of elderly citizens in the world. In 1992, what is known as the Fureai Kippu (caring relationship tickets) movement began, incentivising individuals to support an elderly person in their neighbourhood with the reward of health-care credits. These credits may be spent on their own family’s care needs or saved for future personal use. This movement increased cross-generational cohesion and places elderly citizens in a position of individual care.

In her essay ‘Dear Life: on caring for the elderly’, Karen Hitchcock implores that we have already limited the treatment options we are prepared to offer the elderly and frail in Australia. While these limitations are mostly sound and rational, cries for further limitations, based on horror stories from the US and on cultural winds carrying ideas that treating the elderly is futile or a waste of money, should be opposed.

We need to shift our focus away from limiting care, to improving care for elderly Australian’s. We need to welcome the elderly into our communities and get them to stay there as long as possible, we need government intervention and funding, and community engagement and help.

Ellis Jones challenges stereotypes via effective communication. Talk to us.