Ethical Issues in the Care of the Dying and Bereaved Aged

Morgan John, Morgan D. John

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780895032881
• eBook ISBN: 9781351868662
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Our problems seemingly develop faster than our ability to cope with those problems. The blessing of longer life has brought with it a host of new issues faced by the elderly, their families, and their caregivers. "Ethical Issues in the Care of the Dying and Bereaved Aged", twenty-three essays by some of the most eminent thinkers in the field of death and bereavement, addresses some of these problems. Victor Marshall, Miriam and Sidney Moss, Colin M. Parkes, Dennis Klass, Margaret Somerville and Elizabeth Latimer, as well as other clinicians, have written new material for this book.

PART I

General Issues of the Aged

In this section we examine some of the specific issues that the aged, and those who work with the aged must address. Dorothy Ley, who died soon after the first chapter was written, reminded us that being old is a state of mind. She maintained her joie de vivre: a love of life and living until her death. Our culture tends to regard the elderly as uniform; however, the aging population is not homogenous, exhibiting wide socio-economic and cultural differences. In increasingly multicultural and pluralistic societies such as Canada and the United States, it is essential that caregivers recognize the different attitudes toward the elderly within different cultures and ethnic backgrounds.

The elderly are caught between the cold harsh realities of major demographic changes, and economic plans demanding reassessments of social networks. The elderly in the Canadian population has been risen from just under 10 percent in 1980 and is expected to rise to a peak of about 27 percent in 2031. In 1991, the increase was 12 percent. There will be a particularly dramatic rise in so-called frail elderly, those over eighty-five. For example, it is anticipated that between 1981 and 2001, a proportion of those aged eighty-five or older will increase by 130 percent.

The demographic changes in North America are not alarming per se. Many European countries have lived with 18 percent of their population over sixty-five for the last twenty years. Until recently, Canada and the United States had some of the lowest proportions of elderly in the Western world. It is the rapidity with which it is taking place which gives cause for concern because we are not ready for them.

Mandatory retirement, its associated loss of power, economic dependence, and a system of care that limits the ability to make decisions all diminish the freedom and responsibility of the elderly. It is clear that the majority would prefer to remain in their own communities with support, even at some inconvenience to themselves. The tension that exists between them and their families and caregivers is a direct result of a failure to recognize the elderly as autonomous human beings with rights and responsibilities.

Thompson reminds us that ageism shows itself in subtle ways. The term “ageism” is recent compared with concepts such as “racism” and “sexism.” It refers to a negative and demeaning attitude toward older people and the discrimination that such attitudes both reflect and engender. Ageism must be recognized as a significant force in society and a major barrier to good care of older people. The awareness of ageism is evidenced by the growing literature on the subject and the increasing tendency for such matters to be included in training programs. The fact that such awareness remains uneven is evidenced by the continuing proliferation of examples of poor practice.

For workers in the health care field there is little understanding of the cultural and structural ageism based on ideology, power, and oppression. For example, the fact that discriminatory language reflects the workings of an underlying ageist ideology which marginalizes and demeans older people is not appreciated. As long as staff awareness of ageism does not extend to the cultural dimension of age discrimination, it seems likely that any commitment to anti-ageist practice will remain superficial because of a lack of understanding of the ideological underpinnings.

Thompson indicates that ageism is not simply a lack of respect for older people. It reflects a serious underestimation of the extent and intensity of oppression experienced by older people in barriers to medical treatment, infantilization, denial of sexuality, elder abuse, stereotypes, medicalization, and disablism.

Tappenden believes that changes in burial practice have affected the quality of life of the aged and the bereaved. The first, and one of the most marked changes, is the rapid rise in the cremation rate. While this is not entirely a global phenomenon, it is happening in many parts of the world. In Sweden, the rate is as high as 62.7 percent. The second change is an increase in “scattering” of cremated remains or “doing nothing” with cremated remains. Is it ethical to “do nothing” with cremated remains or is it important to scatter, or inter them and place some form of memorial with them for future generations as a focal point of remembrance? Third, there are more closed casket ceremonies. Funeral directors, and some clergy and psychologists, believe that an open casket at visitation is important in order for family and friends to accept the reality of death. There are even fewer funeral services. More memorial services without the body present are being conducted. The rising cost of traditional funerals and greater availability of low-cost services makes the traditional funeral almost out of reach for many persons. There are fewer religious services and fewer services in places of worship.

The questions that Tappenden challenges are: Do our practices help the grieving process and grieving person or hinder them? Is what we’re doing reinforcing or changing our death-denying culture? Is what we’re doing dignified? Does what we’re doing recognize the value of rituals, however familiar or unfamiliar, however traditional or unique? Is what we’re doing consistent with our other deeply held beliefs and values, spiritual or otherwise, or is it in conflict? Are we considering what family or other survivors need and want?

Marshall believes that a theory of aging and dying should deal with the lived experience of aging and dying. It should try to get at the phenomenology of aging and dying, at the ways in which aging phenomena interweave with age-related death of others in the social experience of an individual, and with that individual’s own experience of finitude. We also need a understanding of aging and dying in terms of social institutions and social structure. He seeks a greater understanding of the ways in which mortality affects the organization of society and on the ways in which this organization around death and dying issues in turn influences the ways in which individuals in later life will experience their process of dying.

The theory that he proposes should incorporate the following theoretical propositions about aging and dying: 1) the shift in the typical age of death to the later years, where it is seen as the normal or typical end of a life course; 2) the longer duration of dying increases the need for institutionalized organizational arrangements for those who are old and dying; 3) the importance of shared meanings for dying as a process, and for death as an outcome or state; 4) the greater desire to exercise control over the “contingencies” of death and dying, such as its timing, association with pain, and social characteristics; and 5) the “cultural lag” in the legitimation potential of culture in highly modernized societies to “explain” death.

Van Heerden points out the injustices of the care for the aged black and the care for the aged white in South Africa. Even in integrated facilities social mixing did not occur between live-in patients (usually black) and local daycare (mostly colored) groups. This was due to the fact that daily activities were in full swing by the time live-in patients returned from hospital treatment clinics. Live-in patients were strangers in the community and socially isolated. They carried the burden of their illness alone and become withdrawn and depressed. The patients felt trapped in treatment decisions and wanted more information to participate in management decisions.

I believe that these chapters will be useful in setting the stage for a discussion of the care of the aged, the dying, and the bereaved in the years to come.

CHAPTER 1

Palliative Care and the Aged in Canada

Dorothy C. H. Ley

I am reminded of Alexander Dumas’ reply to an admirer who asked, “How do you grow old so gracefully?” “Madam,” he replied, “I give all my time to it.” And now so do I, and so do we all.

Being old is a state of mind. There are many of us over sixty-five who have a joie de vivre: a love of life and living that is far greater than some of our younger friends. Perhaps for some, our enjoyment is accentuated by the knowledge that the time we have remaining is shorter and therefore sweeter and more valuable. A famous Toronto surgeon who has been dead for many years once said to me, “Dorothy, life is for the living, and it’s for living. You can’t get it in the bank and get interest on it, you can’t pass it on to your children. You can’t lend it to anyone. All you can do is live it.” How right he was.

There is a widespread, although not universal perception that the elderly are a problem group in society. Certainly there are figures from many countries, including both the United States and Canada that could be interpreted to support this pessimistic view. But equally there are figures that support the contrary view. The elderly are not a problem, but a valuable resource. They are not a burden, but a challenge. Many of the issues surrounding the care of the elderly are uniquely Western in their origin. The status of the elderly varies widely in different primitive societies. In a matriarchal society, the elderly man may be considered useless, whereas the elderly woman is revered for her knowledge and for her position as the mother of the tribe. In hunting and gathering times, the elderly may have been cast off as impediments for the movement of the tribe and therefore its survival. In underdeveloped countries, the average life expectancy may be in the forties, for example forty-eight in Tanzania. (I would not hazard a guess as to what it is in Somalia and Uganda.) In contrast, it is seventy-nine in Canada. Our concern with the care of people over the age of sixty-five and, in particular, with the frail elderly, is seen by the Third World at best as incomprehensible, at worst, a waste of scarce resources. However, in many primitive societies where an elder is living, they are treated with care and concern as a responsibility of the extended family.

We tend to think of the elderly as uniform; however, the aging population is not homogenous. It exhibits wide socio-economic and cultural differences. In an increasingly multicultural and pluralistic society such as Canada and the United States, it is essential that caregivers recognize the different attitudes toward the elderly within different cultures and ethnic backgrounds.

Until recently, in Canada there was a white European culture predominantly of Judeo-Christian religious orientation. That is rapidly changing, particularly in our large urban centers. In Toronto, for example, some 11 percent of the population is Italian, predominantly Roman Catholic, predominantly male dominated. This can pose proble...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication
• Acknowledgments
• Table of Contents
• Introduction
• Part I: General Issues of the Aged
• Part II: Patient and Family Issues
• Part III: Moral Dilemmas
• Part IV: Issues for Health Care Providers
• Part V: Issues of Religious Significance
• Contributors
• Index