The NACA Position on Health Care Technology and Aging no. 18

Serving Seniors With Health Technology: Striking a Balance

A serious consequence of the uncritical use of technology in health care is the increasing intensity with which the health care system is treating seniors. Evidence from British Columbia showed that from 1969 to 1987, hospitalization of seniors increased by 14% although the rate of hospitalization of non-seniors decreased by 16%.³⁴ Most of this increase was due to an increase in surgical procedures performed on seniors, some of which are of questionable effectiveness.

The excessive and inappropriate use of health technology in diagnosing and treating seniors is one of the elements contributing to the increase in service intensity and hence the rise in expenditures for the care of seniors.³⁵ Besides costing more, the increased high technology care is unwanted by many seniors. The fear of being subjected to heroic high-technology measures that would increase the duration of life at the expense of the quality of life is prompting many people to demand the legalization of advance health care directives (including living wills) and other means of refusing treatment. Another consequence is a reinforcement of the misconception that aging per se (and not inappropriate and inefficient use of the health care system) is a major factor accounting for the rising costs of health care.³⁶ This dubious argument has already been used to justify arbitrary discrimination against seniors in the allocation of health care resources.³⁷

Although seniors are most likely to be at risk of too much health care, they are also, paradoxically, at risk of receiving too little care. For example, physicians Carl Kjekkstrand and Henry Moody recently showed that the rates of acceptance of persons aged 65 + into dialysis programs in Canada are much lower than in the United States, despite the fact that older dialysis patients are happier than younger patients and more readily accept the limited lifestyle the treatment imposes.³⁸ The reason invoked by these authors is that resource limitations oblige physicians to ration access to technological interventions--and the most common rationing criterion is age. Physicians may consider a patient's age, even when it is not a determining factor in the prognosis, to decide how aggressively to pursue treatment. To ensure that seniors receive appropriate care, health analysts Helen Kapila and Nicholas Cori suggest that "physicians must strike a precarious balance which, on the one hand, protects the patient against the over-zealous intensivists and on the other hand insures he or she is not condemned to second-class service starved of the undoubted benefits of current medical advances."³⁹

The way to accomplish this is to weigh the benefits and risks of each technological health intervention on a case-by-case basis, regardless of age (or any other social characteristic), taking into account the individual patient's physical, social and psychological resources and personal values. For seniors, this assessment can be effectively provided by a multidisciplinary geriatric assessment team.⁴⁰

NACA thus reiterates the recommendation made in The NACA Position on Canada's Oldest Seniors: Maintaining the Quality of their Lives (1993) that:

Geriatric assessment and treatment units, or their equivalent, staffed by interdisciplinary teams, be provided in every region to act as a resource toprimary-care physicians and specialists.

As well, health professionals need to know how to communicate an unbiased assessment of the benefits and risks completely and clearly to older patients so they can participate fully in making the decision regarding technological procedures.

NACA recommends that:

University and college health education programs combat stereotypes that may bias clinical judgments regarding seniors and train professionals to communicate clinical information completely and clearly to older patients to inform their decisions regarding technological interventions.

Instruments of patient self-determination such as advance directives and living wills can limit the use of technological procedures that prolong life at the expense of the quality of life. Nevertheless, as The NACA Position on Determining Priorities in Health Care: The Seniors' Perspective (1995) cautioned, these instruments must not be subverted to deny seniors potentially beneficial treatments on the grounds that they are too expensive or too limited to 'waste' on an older person. Given the gravity of the consequences of over and under-use of technological interventions in the care of seniors.

NACA reiterates the recommendations made in its previous position paper.

Provincial and territorial governments legally recognize measures that enhance an individuals capacity to make self-determined decisions regarding health care.

Provincial and territorial governments ensure that ethics committees are available in all hospitals and long-term care facilities to monitor the use of advance directives, living wills and power of attorney for personal care to ensure that their purpose is not subverted to deny legitimate treatment to individuals in need of care.

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