countries and few investments have been made in therapeutic interventions to understand, interpret and intervene in the nonphysical pain that is experienced as older patients approach death. Fear and uncertainty among practitioners about the correct dosage of analgesia, fear of addiction to drugs, and anxiety that drugs will work in different and more powerful and dangerous ways in an older population means that patients are refused effective pain relief. Religious beliefs that patients should have a clear mind, uncontaminated by drugs, as they die or that bearing pain patiently is redemptive have shaped pain management among older patients. Fearfulness. Fear stemming from uncertainty about what is happening. Few older people are given clear information about what is happening to them despite the inevitability of death and their awareness of its approach. Cutting off this vital information exchange leaves patients feeling burdensome and a failure to their families; creates uncertainty about whether to accept or reject treatments; and generates anxiety about the right time to prepare to say goodbye, to give their blessing to those they leave behind, to make amends and draw to a close the things that matter. Poverty. Dying is costly and unacknowledged dying even costlier. Cultural norms and community expectations that one will care for family are often significantly stronger in low-income countries than in high-income countries, though this is also changing with the shift in globalised living. Many patients and their families become poorer because of the cost of illness and the expectations of the patient, family, community and health provider that demand constant seeking and paying for cures. In a study carried out in P a l l i a t i v e c a r e East Africa, families in Kenya, Uganda and Malawi, when asked about their care patterns, explained that they no longer had any money in the household because they had been forever seeking cures and never finding them. Lack of conversations with health providers about the likelihood of illness leading to death meant that families felt they had to show that they had done all they could to keep the person alive; for many what was important was the visibility of effort. Neglect. The opposite of families seeking curative treatments even though death was inevitable was the failure to look for any care at all. The undocumented global burden of the neglect of the ageing, as social networks, kinship groupings and extended family systems become more disparate, is particularly acute when elderly people require palliative care. Older people suffering from dementia are the least likely to receive palliative care in high-income countries, and a range of reports on dementia care have identified that too often people are receiving undignified treatment and are dying in pain (Gott and Ingleton, 2011). Identification of older people who would benefit from palliative care is challenging in low-income settings, where cost sharing and out-of-pocket expenditure for health determine family priorities in seeking care. Rebuilding the palliative care service To build an integrated and comprehensive palliative care service that is responsive to the needs of the elderly requires a seamless and managed system with an emphasis on enhanced communication, and more determined case finding. Integration is the buzzword for all health systems, but Gott and Ingleton (2011), Commonwealth Health Partnerships 2015 27 Figure 1 Number of chronic disorders by age group 100 90 80 70 60 0 disorders 1 disorder 2 disorders 3 disorders 4 disorders 5 disorders 6 disorders 7 disorders ≥8 disorders Patients (%) Age group (years) 50 40 30 20 10 0 0–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85+ Source: Barnett et al., 2012
Commonwealth Health Partnerships 2015
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