A Public Health Strategy for Living, Aging and Dying in Solidarity

Designing Elder-Centered and Palliative Systems of Care, Environments, Services and Supports

Mary Beth Morrissey, Melissa Lang, Barney Newman

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315350615
• Edition: 1
• Topic: Commerce
• Subtopic: Industrie des services

With more people living longer lives, there is increased importance in the health care industry on improving services for the elderly. This comprehensive book gives an expert overview of the topics and challenges, along with imperative ethical and legal frameworks. The book also details existing programs and benefits in relation to a realistic portrayal of population needs. Other important issues are covered such as long-term palliative care and hospice, other vulnerable populations, elder abuse, public-private collaboration, evidence-based policy-making, and much more.

OneThe crisis of suffering for older Americans

1Social ecology of agingCritical theoretical perspectives in aging and public health policy for the twenty-first century

IIntroduction

As we approach the end of the second decade of the twenty-first century amidst relative chaos in the national policy arena, policy makers are positioned to seize upon a rare horizon of opportunity to alter the trajectory of suffering that characterizes growing old in America. More specifically, policy makers can mitigate elder suffering associated with both societal conditions and the burdens of individual illness and functional limitations, and they can afford elders the chance to live and age comfortably, and to die in ­solidarity. By living, aging, and dying in solidarity, we mean to suggest Aristotelian notions of flourishing that implicate meanings of community and subjective and intersubjective well being or eudaimonia (Drummond, 2002; Steptoe, Deaton, & Stone, 2015), but we expand upon those notions of well being by including within their purview meanings of “palliative,” such as dwelling in the palliative embrace of supportive communities. An Aristotelian sense of well being is related to the intentionalities, teleological and vocational life goals, and purposes of a moral agent, and the fulfillment of intentionalities in light of such individual goals, as well as the goods of moral agency itself as philosopher John Drummond (2002, 2008) has explicated.

Now more than any other time, policy makers and policy advocates—together with the older adult stakeholders on whose behalf they commit themselves—must converge on the vortex in the political economy of the early twenty-first century to forge coalitions, mount active resistance to regressive policy, and lead change processes that will directly impact and nullify conditions of oppression and suffering that burden older Americans and interfere with their attainment of life goals. We call upon such policy makers, advocates, and coalitions, including older adults themselves in diverse roles, to work collaboratively as agents for change, building environments that make conditions possible for palliation of elder suffering, elder flourishing, resilience in the midst of suffering, and the fostering of elders’ deep relational connection with meaningful others and their community. In this chapter, we focus on understanding the manifold environmental layers that shape the experience of suffering and growing old in America, including the complexity of social systems and the recalcitrance and inhospitability of the aging and public health sectors themselves—what we describe as the social ecology of aging. Drawing on the history of various movements in aging and person-centered care, including the tensions around the goals of such movements, we reframe the goals of living, aging, and dying, as comfortably and palliatively as reasonably possible, in fundamentally social terms. In light of the main sociopolitical and economic drivers of aging and health policy, we propose an elder-centered care approach that responds to the social suffering of older persons and addresses inequities in accessing essential health and social services, supports, and care.

The goals of an elder-centered care frame are multiple:

• To define the social problem of suffering for all older persons, especially vulnerable, frail and seriously ill older persons.
• To identify structural and systems barriers to older persons’ pursuit of life goals, flourishing, and comfort.
• To raise awareness of elder needs and rights.
• To inform and guide policy planning and the development of model progams and effective practices.
• To craft public health and global public health agendas designed to change the current paradigm to one more capable of meeting the needs of older people in their social, cultural, and community contexts.

Such a paradigm shift involves changing the conditions of older adults’ embedded environments, modifying social and economic determinants of health, and, according to public health law scholar Lawrence O. Gostin (2014), making comprehensive health goods, services, and facilities available, accessible, affordable, and acceptable, both ethically and culturally. The right to health requires nothing less.

This chapter is organized into four main sections:

• Defining the social problem of elder suffering in the context of the environmental landscape.
• Describing the social ecology of aging and its principal ecosystems.
• Addressing the shift to elder-centered care.
• Explicating an elder-centered public health strategy for improving elder health and well being.

IIFraming the social problem of elder suffering: Social ecological and environmental contexts

A sine qua non of policy development in aging and health is understanding the nature of the principal social problem that drives aging and health policy making: the problem of suffering. In this chapter, we describe the magnitude of the problem and its critical dimensions as part of an overview of the larger social ecological and environmental landscape, as well as argue for a firm and settled commitment to change policy that has a detrimental impact on older adult beneficiaries. The types of factors shaping the landscape of global suffering for Americans as they age into their later years include individual-level variables; variables at the sociopolitical, economic, and cultural level; and factors that have both micro- and macrosystem implications and consequences. For example, chronic conditions, functional limitations, and disability burdens have a direct impact on elders’ personal health status, but also have important systems implications. A goal of this chapter is to explicate the complex entanglements and relationships of experiences and outcomes for the older person as an individual in relation to the larger systems in which they are embedded. In addition to personal health characteristics, among the mix of factors we consider and discuss in this chapter are sociopolitical movements; ecology of policy; demographic trends; caregiving resources and risks of elder abuse; social and economic determinants of health and inequities in access to care; inadequacy of aging, health, and social systems, including community-based services and supports; workforce gaps; a rapidly changing climate ecology and concomitant risks of displacement and homelessness; and inadequate understanding, assessment and measurement of suffering. These multidimensional factors are described and discussed more fully below.

IIISocial ecology of aging and its ecosystems: Interaction of macro- and microsystems

Essential to the aging and public health focus of this book is describing a social ecology of aging and its ecosystems. The social ecological perspective on elder human development, drawn on throughout the book and explicated in this chapter, helps to make sense of the range of lived experiences of growing old—the multiple faces of suffering, including vulnerability, frailty, limitation, and dependency, as well as agency, growth, flourishing, and relational connection. The book’s chapters are organized around key questions to help unpack the critical components of the ecology of aging in its breadth, depth, and complexity:

• Who comprises the older adult population of interest and the stakeholders in elders’ families and communities that are the book’s focus?
• What are the critical policies, programs, and benefits intended t...