This small volume, which is essentially a plea for positive discrimination towards the old (especially the sick old), is written by a general physician in a large University teaching hospital. Her years of care of sick patients in public hospitals have led her to consider how medicine and society actually treat older people when they need such care. She argues, using both statistics and anecdotes, that contrary to received wisdom we actually discriminate against the elderly in relation to possible life saving practices on the basis of their age.
She debunks the common perception, in both the media and in medical circles, that the elderly are inevitably over-treated against their wishes and that most older patients and their families are clamouring for all possible treatment options. She does this by distinguishing the actual workings of the Australian publicly funded medical system from those of the predominantly privately funded US health system. In the latter there is often a financial imperative to treat all patients no matter what their age or frailty, whereas in the Australian and UK public health systems the imperative is to get the patient out of hospital as quickly as possible with whatever care is deemed appropriate. She argues than in these systems patients are much more likely to be denied care on the basis of their age than be forced to undergo unwanted treatment. Although in a spirit of absolute fairness she does provide examples of possibly unnecessary treatment being offered to patients in the Australian private health sector.
One of the reasons why old people don't receive the best medical care is because of the fragmentation of the health and welfare systems. It becomes very difficult for a patient with several health and social disabilities to be seen as a person rather than a receiver of separate medical and care interventions. They are no longer seen as someone who needs coordinated health and social support to be enabled to continue living at home safely, but as a series of disconnected problems. The health system is arranged around the various body systems; so heart disease is considered by the cardiologists and renal failure by the nephrologists when any change in the treatment of one is very likely to lead to a problem with the other. The social services are usually managed by staff without health expertise so their ability to understand and coordinate complex care packages can be limited.
She notes that when young people with severe spinal injuries are cared for in nursing homes this is considered “awful”, however no concern is raised about the many elderly people with physical and cognitive disabilities who receive care in the same places. Such places (as well as acute medical services) also often infantilise older people so that they are no longer Professor T but “that cute old guy.”
Her comments about the usefulness of advance care plans for older people are very pertinent. She, like the reviewer and her colleagues, is concerned that younger doctors and family members are pushing old people into saying that they do not want treatment if they become ill again. These practices do not accord well with the knowledge that most of us accept disability, particularly if it develops over time, and when we reach the stage that we had previously decided would be the line in the sand many of us will want treatment. Such plans need to be reviewed as changes occur so that we are not encouraging patients to believe that we are only interested in cost saving or in their not being a burden to their families and the system.
Her suggestions include considering the whole person, not just their different body systems, but also their wishes and goals for their lives in discussion about their care. Such pleas will not be new to many readers of this journal, nor to geriatricians or those who work in palliative care. The benefit of this book is perhaps to lend it to one's general physician and surgeon colleagues and students who are thinking about medical or social work careers.
