“Social injustice is killing people on a grand scale.”
(WHO, 2008, p 4)
The graphic above, from the United Nations Department of Economic and Social Affairs, should be both sad and startling. It is shocking that in our modern era the average life expectancy can vary from the 40’s to well into the 80’s. And while global social policy is not the topic of this discussion, the graphic highlights the significant health inequity that exists worldwide. And that perhaps development of sound health policy cannot exist in isolation from good social policy.
Consider the United States. The Centers for Disease Control publish morbidity- adjusted, or healthy life expectancy, statistics for each state. This is an estimate of healthy years left for an individual aged 65. It is interesting to note that a 65 year old resident of Utah may expect greater than 15 more healthy years, while a 65 year old resident of Nevada may expect less than 13 (CDC, 2013).
There is a significant movement to eliminate these tremendous health disparities within the public sector.
I would like to highlight a few of them, particularly the work being done to decrease health disparities for the aging community.
The Commission on Social Determinants of Health (The Commission) was established in 2005 by the World Health Organization (WHO). This Commission calls for governments worldwide to eradicate health inequities within one generation. This appeal is made to all countries, regardless of economic status or developmental position. It is a collaboration of policy on a global level. The Commission calls for societies to address health inequalities through social, economic and health care policy. The executive summary of the Commission highlights three recommendations and action steps. The first of these is to improve daily living conditions. This includes promoting health throughout the lifespan, including the process of aging (WHO, 2008). The Commission asserts that governments should make health a top priority. This may be accomplished by assuring that policies across all disciplines (economic, education, transportation, trade etc.) complement, rather than contradict, the development of health care policy.
The National Institute on Aging (NIA) has created a strategic plan to eliminate health inequality among the elderly. The NIA is specifically addressing disparity among racial and ethnic minority populations. Current population trends anticipate that the number of Hispanic Americans over the age of 65 will increase eleven-fold by the year 2050 (NIA, n.d). This poses unique opportunities for the government to direct its efforts toward specific populations. The NIA contends that to eliminate health disparities among populations research must include not only the physiologic components of aging but the economic, social, genetic and environmental processes.
These health care inequalities persist through the availability of palliative care services. Research has demonstrated persistent barriers to access and utilization of palliative care services among minority groups (Smith & Brawley, 2014). The research further indicates that African Americans are more likely to exhaust their financial resources in end of life care than their Caucasian counterparts (Martin et al, 2011). Advocates of palliative services suggest a multilevel intervention to improve inequalities through policy development. This includes well-funded research, education for providers, an increase in public awareness and improved care delivery models (Smith & Brawley, 2014). A bill has been introduced in Congress to support this multidimensional approach to end of life care. H.R. 1666 was introduced in the House of Representatives in 2013. A similar bill was introduced in the Senate in 2014. It directs leaders of the Centers for Disease Control, the Department of Health and Human Services and the Administrator for the Health Resources and Service Administration to address palliative service needs through funding, education and strategic research collaboration (Congress.gov) Although this bill died in committee it represents great promise in the public approach to palliative care.
We can see that on a grand scale there are initiatives to eliminate health care inequality for the aged. The WHO and the NIA provide a framework for successful policy change. Congressional leaders are building policy initiatives. Next week we will discuss how federal and state reforms are affecting the aging population, addressing health care disparities and influencing the delivery of palliative care.
References
Centers for Disease Control. (2013). State specific healthy life expectancy at age 65 years. Retrieved from http://www.cdc.gov/about/cdcdirector/life-expectancy.html
Congress.gov. (n.d.) H.R. 1666- Patient centered quality care for life act. Retrieved from https://www.congress.gov/bill/113th-congress/house-bill/1666
Martin, M.Y., Pisu, M., Oster, R. A., Urmie, J. M., Schrag, D., Huskamp, H.A… Fouad, M.N. (2011). Racial variation in willingness to trade financial resources for life-prolonging cancer treatment. Cancer, 117(15), 3476-3484.
National Institute on Aging (n.d.). Health disparities strategic plan: Fiscal years 2009-2013. Retrieved from http://www.nia.nih.gov/about/health-disparities-strategic-plan-fiscal-years-2009-2013/missionvision-statement
Smith, C. and Brawley, O. (2014).Disparities in access to palliative care. Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2014/07/30/disparities-in-access-to-palliative-care/
United Nations Department of Economic and Social Affairs (UN DESA). (2011). World population prospects: The 2010 Revision.
World Health Organization (WHO). (2008). Closing the gap in a generation. Commission on Social Determinants of Health, Final Report. Retrieved from http://www.who.int/social_determinants/thecommission/finalreport/en/
the value of palliative care 
Perhaps another method that could be done to decrease disparities among the populations who will come to choose palliative or hospice care, is to implement a Patient Order for Life Sustaining Treatment (POLST). The POLST document that turns patient wishes into medical orders is recommended to be implemented on a national level (Hickman, Sabatino, Moss, & Nester, 2008). It seems that allowing all persons the ability to make their own wishes into medical orders would, in a sense, deliver equality among persons who chose palliative or hospice care. Hickman et al. (2008) also explain that with individual state regulation that enacting the POLST on a national level would come with great resistance. There are many areas of inequality among those who qualify for palliative care such as location and education. Research points to a resulting adherence to patients wishes in a variety of care settings when using POLST forms (Hickman et al., 2009; Schmidt, Hickman, Tolle, & Brooks, 2004).
References
Hickman, S. E., Nelson, C. A., Moss, A. H., Hammes, B. J., Terwilliger, A., Jackson, A., & Tolle, S. W. (2009). Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting. Journal of palliative medicine, 12(2), 133-141.
Hickman, S. E., Sabatino, C. P., Moss, A. H., & Nester, J. W. (2008). The POLST (Physician Orders for Life‐Sustaining Treatment) Paradigm to Improve End‐of‐Life Care: Potential State Legal Barriers to Implementation. The Journal of Law, Medicine & Ethics, 36(1), 119-140.
Schmidt, T. A., Hickman, S. E., Tolle, S. W., & Brooks, H. S. (2004). The Physician Orders for Life‐Sustaining Treatment Program: Oregon Emergency Medical Technicians’ Practical Experiences and Attitudes. Journal of the American Geriatrics Society, 52(9), 1430-1434.
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You brought up some excellent points regarding the health disparities specific to palliative care. I also appreciate the examples you used of the public sector and their role in helping to ease this burden. I was shocked by the statistics you shared.
I was mostly interested in the section you posted about minority groups and palliative care. Do you think that part of the reason certain ethnicities do not fully utilize palliative care is due to their specific culture? Some cultures focus on family support of their elderly and dying loved ones, with grandparents/great-grandparents remaining in the home under the family’s care. Recognizing and educating them that palliative care would be available to support them, not take over care of their loved one, would be important to emphasize. However, I can’t help but wonder if this plays a role in their using palliative care resources less frequently.
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Thank you for addressing the issue of healthcare disparities when it comes to palliative care. I am curious if you came across anything in your readings regarding another disparity related to palliative care: rural settings? My upbringing was in a rural area and I have had the chance to reflect on many different realities of healthcare disparities as I have transitioned from living in a very rural area to a large metropolitan area. I had never applied the concept of health disparities in rural areas to palliative care, but it seems to exist. Downing and Jack (2012) note that models of palliative care in urban areas cannot be automatically applied to rural settings. Do you think this may be the same with other parts of our population, such as different racial and ethnic groups?
Downing, J., & Back, B.A. (2012). End-of-life care in rural areas: What is different? Current Opinions in Supportive and Palliative Care, 6(3), 391-397.
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