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TRAFICCPAD

Chapter 21 - Social and Ethical Aspects

Respect

Over the years, senior adults have gained experience in life. In every society, they are most of the time recognised as wisdom holders. In addition, many continue to take community responsibilities despite being retired.

The question of life expectancy slowly surges and becomes evident to them since most of their time has already been lived. However, remaining lifetime is an individual matter that is influenced by the personal genetic background and the environmental hazards.

"Healthy octogenarians have more time to live than sick septuagenarians, and nonagenarians can enjoy an additional four-year life expectancy that will still be over one year at the age of 100.”

Admiration

Besides the ability to reach a respectable age, senior adults actually want to avoid a premature end to life. Lifestyle and nutritional aspects of daily living thus match epidemiological projections showing that the annual probability of dying is kept below 10% until the age of 70 years. In other words, the risk of dying rises from 1 in 10,000 at the age of 10 years to 1 in 10 at the age of 70 years and almost 1 in 1 at the age of 100 years.

"Similar trends are observed throughout the world, suggesting a welcome global improvement of living conditions for the general population.”

Attention

The prevalence of chronic conditions at an advanced age will continue to increase. In cancer patients, concomitant cardiovascular diseases will be present in up to half of the cases and more metabolic conditions such as diabetes mellitus are seen. Cognitive deficits are present in more than a quarter of senior adults after the age of 80 years, thus raising questions about comprehension and informed consent. Senior adults also accumulate general risk factors for mortality such as functional decline, delirium, falls, incontinence, and neglect.

"An interdisciplinary approach is an attractive and efficient way to tackle the multiple problems routinely encountered in senior adults.”

Information

Senior adults were educated several decades ago when DNA had not been described and wireless communications had not even been imagined. Today, they listen, although what is said does not always correspond to what is understood. This may sometimes lead to misunderstandings and unrealistic expectations. They read and surf the internet to learn that 5-year breast cancer survival probability is over 80% regardless of age at diagnosis, provided standard adequate treatment is offered. Interestingly, published surveys have shown that quality of life (QoL), though being an ill-defined concept in senior adults, is more important for them than survival length.

“Additional efforts to properly communicate good news as well as bad news may help to share an active partnership with senior adults.”

Protection

In a democracy, senior adults are voting citizens, and their influence on critical decisions is by no way to be minimised. “The grey power” is, therefore, a growing reality garnering more attention from politicians and from society itself. About half of the senior adults live on their own in the urban community, and the proportion decreases with age. In parallel, there is a feminisation of the oldest old because women have a definitive life expectancy advantage on men. And in many communities, only half or less of those with biological descendants can rely on help and assistance of a nearby living child.

Thus, advanced directives should be actively promoted by health professionals who must then obey their content and listen carefully to the therapeutic representative.

“Needs of senior adults are therefore becoming more and more specific to the societal Transformation of their daily environment.”

Diagnosis

Senior adults are prone to cancer, with over 2,000 new cases per 100,000 inhabitants per year. This is a ten times higher incidence in comparison with the population below the age of 65 years. Accurate diagnosis leading to further appropriate tests aiming at the best-designed treatment is the single way to maintain or improve the quality of the remaining time to live.

"Professional geriatric evaluation, together with scientific assessment of cancer cells by the pathologist and precise medical oncological clinical staging, is mandatory.”

Care

Too many different drugs are prescribed to senior adults because of their comorbidities. The risk of interactions and detrimental side effects that can occur during the management of cancers and other diseases are well known. Poor outcomes have been reported, including fatal events caused by standard drugs. In addition, unlicensed substances, sometimes of a very poor quality, are used by as much as 50% of cancer patients. Optimal care should therefore encompass the traditional aspect of “bona fama” and complementary medicines.

“Four fundamental ethical principles must govern medical action with the aim of finding a valid balance between each of them, which are the following (Figure 2).”

The balance to be found between the four fundamental ethic principles

 
  • Autonomy means the capacity to decide what is good or not good for oneself; senior adults should fully understand the problem before giving consent to further tests or therapeutic measures.
  • Justice (equity) is the capacity for a group to distribute wealth on an equal basis and above all for the most in need; senior adults should benefit from the resources generated within a community to maintain and/or improve health conditions.
  • Beneficiency is the capacity to do what is good for the other and of sanitary benefit; health professionals should use their skills to maintain and/or improve health conditions of senior adults.
  • Non-maleficiency is the capacity to not harm the other; health professionals should take every precaution to make sure that health conditions of senior adults are not at risk to be damaged by diagnostic or therapeutic measures.

Time

As is the case with children in paediatrics, senior adults are most of the time accompanied by loved ones. But these may not be members of their family. The traditional composition of families has indeed undergone many changes during the past century in relation with the observed increased life expectancy. In many countries, a high incidence of divorce has profoundly modified intra-familial communication and composition. Senior adults and proxies may thus require more time for explanations and understanding of their personal situation. Distance to and from health centres may hamper access to care, requiring transport facilitation to be organised and social intervention to be implemented.

"Family and/or the most significant proxy should not be left without help and assistance to minimise the risk of burnout.”

Caution

Senior adults use vulnerable and frail organs with a progressive reduction of the tolerance to stress and a loss of functional reserves. Striated muscles are replaced by increased fat, kidney function loses as much as 1 mL/min/year from the age of 40 years, and liver function is not as efficient at 80 years as it was at 50. But the worrying limitation is the incidence of cognitive troubles and the occurrence of dementia, which markedly increase with age to reach unexpected levels.

"Short assessment will provide useful information but will not preclude a more thorough neuropsychological evaluation to ascertain harmlessness.”

Freedom

Thoughts and beliefs are daily life companions allowing the development of a personal spirituality. In many senior adults, the persistence or the resurgence of religious feelings must receive an appropriate answer. To cope with cancer, senior adults tend indeed to use prayers first before music, exercise, or meditation. On the other hand, in a few countries around the world, assisted suicide and/or euthanasia are now integrated in medical practice and are supported by the population. Beside palliative care, this is the end chosen by a minority of senior adults when facing physical or psychological suffering brought on by cancer. None of this should be ignored.

Please remember that historians judge the level of progress achieved by successful civilizations through the way they care for the weakest, the poorest, and the oldest.

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