My mother was an active, healthy 91-year-old when she fell on a marble floor in her high-rise, badly damaging three vertebrae. She didn’t tell me or go to a doctor, so by the time I arrived in Florida four days later she was in agony, having taken nothing stronger than Tylenol. No doctor I reached that night would make a house-call. She kept moaning, “I want to die.” The next day her aide and I somehow got her to a doctor, who prescribed something so inadequate that she was screaming the next night. The facts blur, but eventually in desperation I called a friend, a pediatrician in another city, who said to insist on Oxycontin. I did, and that night my mother slept. And so did I. But the pediatrician also said, “This is standard medical practice. So your mother is ninety-one? They don’t want her to become an addict.” (This was before the opioid epidemic, long before doctors were getting blamed for over-prescribing.) My mother recovered; she learned to walk again normally. She was never addicted.
No adult child should ever have to hear a parent say that she wants to die for untreated pain. Yet, as Dawn L. Denny and Ginny W. Guido, two nursing professors, report, adults over 70 are the group at the highest risk for undertreatment of pain. In long-term care settings, a fourth of older adults may not receive adequate pain relief. Malpractice can be defined as injurious, negligent practice. Undertreating elder’s pain is only one kind of malpractice against those among us who have survived into later life, a group that now includes me and most of my friends. Hard as it is to say after my mother’s ghastly, traumatizing ordeal in Florida, what happened is not by any means the worst story. Medical ageism takes many forms--in nursing, medicine, and surgery, in care given by EMTs and in hospitals, in treatments for disease and for acute attacks. Over the years I have collected startling scientific news about patterns of neglect.
One of the startling examples comes from a study of 335 Welsh patients, whose ages ranged from as young as 30 to 101. It found that the length of a cardiac resuscitation attempt declined with age, with those aged over 70 receiving a median resuscitation time that is astonishingly shorter: 6 minutes versus 13 minutes.
If you are a woman with breast cancer who is over sixty-five, the odds of not receiving chemotherapy are seven times greater than for a woman under fifty. Indeed, a survey of physicians in the Oncologist concluded, many cancer specialists would deny older people with colon, breast, lung and prostate cancers the potentially life-saving treatments that they would offer younger people, even in circumstances when the former could benefit as much.
Older patients often come out of hospital stays sicker than they went in: they may need quick rehospitalization or die of causes like sepsis, heart arrhythmia, and pneumonia, which might be prevented. There may be many reasons why. But one Harvard study of 1,000,000 Medicare patients, found that women physicians are better than male doctors at keeping down re-hospitalizations and preventing such deaths. If male doctors achieved the same outcomes, the article in Journal of the American Medical Association Internal Medicine estimated, annual deaths of Medicare patients would drop by 32,000. What behaviors, training, or attitudes, might explain this gendered difference in care? I’ll come back to this and discuss how ageism works.
These examples--inadequate CPR, unequal treatment of some cancers, and hospital neglect—are evidence-based instances of undertreatment. There are also systemic problems that disparately impact older people. Fragmentation of care is one, where patients with multiple issues are seen by different and uncoordinated specialists. These can turn deadly serious, but bias is harder to measure.
Undertreatment has many causes, and ageism is a major one. Ageist assumptions that many lay people share —arising from ignorance about the variable experiences of old age and impatience at bodily difference—produce disabling fears of older people themselves, and of old women in particular, the majority of the very old. Much ageism is sexist ageism combined with ableism. Compound stereotypes and fears are confirmed by the “medical model,” which takes for granted that all people growing into old age are sick, frail, or gaga. In decline discourse, aging brings no benefits; people can be considered no longer quite human. The first chapter of my most recent book, Ending Ageism, or How Not to Shoot Old People, is titled #StillHuman.
Heterogeneous as old people are, privileged as some may be, as a group we endure many attributes of other numerical minorities: invisibility and hypervisibility, intolerance of our appearance, lack of audiences for our subjectivities, underestimation of our trials, dislike of our alleged characteristics or disgust at our apparent weaknesses.
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Tikkun 2018 Volume 33, Number 3:6-9