Biomedical subjects
Kevin C Fleming
Publications and source records attributed to Kevin C Fleming.
Ethical issues in geriatrics: a guide for clinicians.
Because of demographic trends, it is reasonable to expect that clinicians will care for an increasing number of elderly persons with challenging medical and psychosocial problems. These problems and issues, in turn, may lead to daunting ethical dilemmas. Therefore, clinicians should be familiar with ethical dilemmas commonly encountered when caring for elderly patients. We review some of these dilemmas, including ensuring informed consent and confidentiality, determining decision-making capacity, promoting advance care planning and the use of advance directives, surrogate decision making, withdrawing and withholding interventions, using cardiopulmonary resuscitation and do-not-resuscitate orders, responding to requests for interventions, allocating health care resources, and recommending nursing home care. Ethical dilemmas may arise because of poor patient-clinician communication; therefore, we provide practical tips for effective communication. Nevertheless, even in the best circumstances, ethical dilemmas occur. We describe a case-based approach to ethical dilemmas used by the Mayo Clinic Ethics Consultation Service, which begins with a review of the medical indications, patient preferences, quality of life, and contextual features of a given case. This approach enables clinicians to identify and analyze the relevant facts of a case, define the ethical problem, and suggest a solution.
The perils of single-payer health care.
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A cultural and economic history of old age in America.
The lives of today's elderly population have deep historical precedents by which we can better understand current social policies, health care, and retirement. The history of old age in America is more complex and varied than most people realize. This history has been shaped largely by the search for economic security. In the agricultural economy of preindustrial America, few individuals saved sufficient resources for their declining years, and most elderly people either continued to work or lived in dependent poverty. More than any other factor, the lack of family members willing or able to provide for an elderly relative resulted in the relative moving to the dreaded poorhouse. Passage of Medicare and Medicaid legislation resulted in the rapid development of commercial nursing homes, accelerating the trend away from nonprofit and government facilities. However, serious deficiencies in care have continued to occur, prompting additional federal legislation. Knowledge of the history of aging in America can provide a useful touchstone: it can expose past problems that could happen again, identify what is worth preserving from the past, and help us avoid relearning painful lessons.
Caregiver and clinician shortages in an aging nation.
Despite a burgeoning elderly population, the number of nurses and other providers of direct care has declined to critical levels at many health care facilities. There are also insufficient medical clinicians to meet the demand for health services. A shrinking workforce, an aging population, financial pressures, and increased consumer demand will translate into severe personnel deficits in the future. Similarly, family fragmentation and the trend toward bureaucratization of long-term care have reduced the availability of informal caregivers. Younger workers should be considered a scarce resource for health care organization and planning purposes. The ability of the United States to meet its entitlement promises is likely to be compromised by a reduced labor pool and simultaneous budgetary constraints. Because good geriatric care is often labor-intensive, meeting this goal poses an increasing challenge.