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Pain is real, not a myth

Letter, The Age

It is tragic that older people commit suicide (The Age, 17/1). The National Coronial Inquiry Service estimates that two people over the age of 80 are taking their lives every week. The most common method is hanging.

Ian Hickie suggests older people commit suicide because of myths and negative stereotypes about ageing, pain relief, hospitals and how the health system treats elderly people. Are these myths?

Recently, an elderly woman living in an aged care home died in excruciating pain because no one was suitably qualified on the night shift to administer the prescribed morphine. The woman’s daughter was so traumatised she could not remain at her mother’s bedside to hold her hand.

We do not need motherhood statements about healthy ageing. We need political action to ensure older Australians are valued and receive the quality of health care that they deserve.

 

Sarah Russell, Northcote

 

Our elderly need homes, not warehousing

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Language  shapes our sense of place. Residential aged care facilities are places that our most vulnerable older people call home; the home that will, for most, be their last place on earth. The term “facility” dehumanises aged care. Facilities are built to perform functions in the most efficient manner. In contrast, a home is a welcoming place, where friends and family drop in for a cuppa or a chat,   and, if we need help, assist us around the house, the garden or even with dressing.

Since the 1990s successive governments have failed to heed the forecasts of demographers on population ageing. Now with the need for housing and care options exceeding the capacity of families and communities, an investment boom is taking place. Private equity firms, foreign investors and superannuation and property real estate investment trusts are entering the residential aged care market in larger numbers. And they are building larger facilities.

According to the Australian Institute of Health and Welfare, half of all residential aged care facilities had more than 60 places in 2014 compared with 28per cent a decade ago. Increasingly built on reclaimed industrial land, aged care facilities now serve as places to warehouse our parents and grandparents,  removed from daily community life.

The Aged Care Financing Authority estimates the residential aged care sector requires $31 billion of investment over the next decade. Handy if this can come from private funds. To attract investors, the Productivity Commission recommends a competitive market with reduced regulation. In a recent letter to the editor (8/1), the chief executive of the Aged Care Guild listed “infrastructure, technology, and training and consumer choice” as the improvements “unleashed” on the sector. Care was not mentioned.

Using language of facilities, scale efficiencies, corporatised operations and the generation of better margins enables investors, industry bodies and politicians to respond in solely economic terms, forgetting they are building a home where care is provided for us, our parents and grandparents.

Policies seeking to improve care are bureaucratic and largely meaningless because they are based on the language of business facilities. While we need strong standards and monitoring of aged care services, we equally need to change the prevailing view of ageing, and what it means to provide a home and care.

We need to include the broader moral view on the question of how  we, as a community, can create an age-friendly environment for all.

We hold deeply negative attitudes to ageing, lumping together all  older people as  a drain on the economy, separating them from the life span, and pitting them against the young for resources. Fearful of our own mortality, frailness and dependence on others, we stigmatise older people. While we respect those who can take care of themselves, or who are “not a bother to anyone”, those who are frail and needing care are not accorded the same respect. This equates to a failure to recognise our parents and grandparents as full human beings. Within aged care, these social views of old people as worthless and unproductive are  reflected and magnified when faced with the daily reality of frail human bodies. When we treat people as “other”, when the stereotypes structure policies and culture, we treat people carelessly.

We need a moral approach to the care of older people based on kindness. We need to recognise in older people an inner life much like ours; complex, full of memories, filled with desires, passions and vitality even if their bodies and minds are no longer as agile. There is a significance to late life. It has purpose. Its meanings need to be seen and celebrated.

We need to shift our view of frail, older people to include the recognition of their contribution to our nation’s prosperity over the whole of their lives. We need to value the contribution people who need care can, and do, make to the lives of others.

Everyone is responsible for the culture of ageing. We need effective leadership from governments, the private sector, businesses, families, community members and older people themselves. We need to create places where we can live the end of our lives as part of the community, in homes where we receive care with respect and kindness. Our sense of belonging is deeply rooted to our sense of place and purpose. We have a moral responsibility to create age-friendly places for all.

Dr Kathleen Brasher is a member of the WHO strategic advisory committee for the Global Network of Age Friendly Communities

 

 

Entrenched sexism in surgery

For decades, the Royal Australasian College of Surgeons turned a blind eye to the entrenched sexist culture within surgery. After recent publicity, they have finally opened their eyes. They can no longer deny sexist surgeons operate within hospitals around Australia.

The college appointed a group of independent experts – Rob Knowles, Helen Szoke, Graeme Campbell, Cathy Ferguson, Joanna Flynn, Judith Potter and Ken Lay – to advise them on what should be done.

The first thing was to determine the extent of the problem. Was it just a few rogue sexist surgeons? Or is sexism pervasive within surgery?

The Expert Advisory Group found sexism is commonplace in surgery. A survey found 49% of fellows, trainees and international medical graduates were subjected to “discrimination, bullying or sexual harassment.”

The large number of victims comes as no surprise to those of us who have worked in a hospital. Hospitals operate on a hierarchical structure with surgeons positioned at the top of the pecking order. They call the shots.

Sexist surgeons do not leave their bullying behaviour at the operating theatre door. They bully other health care professionals and patients. They also take their bullying behaviour home.

Sexist surgeons have a strong sense of entitlement. They are in command, both at work and home. Not surprisingly, the expert committee found protagonists had a lack of insight about their bullying and sexist behaviour. This lack of insight into their internalised misogyny will make changing their behaviour difficult.

The expert committee noted that sexist behaviour has negative implications for patient care. I recently observed a senior surgeon disagree with a colleague about a female patient’s analgesia. The surgeon spoke very loudly whilst the patient lay quietly in her bed. Afterwards, the patient was very distressed. She asked me if the surgeon wanted “to euthanise me?”

I later asked the surgeon not to talk about the patient within her earshot. I explained how upset she was about the altercation at her bedside. He stormed off, shouting: “I will not listen to this.”

The Expert Advisory Group found “known bullies” are untouchable. Bullying among surgeons has become normalised as a culturally accepted behaviour. Perpetrators are more likely to be promoted than held to account.

Most surgical departments have at least a few bullies. It is likely that these bullies are well known to the hospital’s management. Yet, despite legal obligations to provide a safe workplace, hospital managers rarely reprimand surgeons for their sexist behaviour.

The demonstrable lack of consequences for perpetrators encourages some surgeons to continue to abuse their power. Hospital managers may be reluctant to take action on badly behaved surgeons for a range of reasons. They may fear the financial and reputational consequences. Hospitals fear both publicity and litigation.

There is an expectation among some senior surgeons that junior trainees should endure the same training circumstances as those in place when they trained. Trainee surgeons do not complain for fear of being seen as weak or unsuitable for surgery. They fear being black-balled.

Those who have the courage to complain risk career suicide. Sometimes a surgical career is over before it starts.

The expert committee also identified “bystander silence” as a serious problem. Within a culture of fear and reprisal, colleagues who witness bullying, discrimination and sexual harassment are rarely prepared to complain. They see no point in making a complaint.

Complaint processes protect the status quo. The person responsible for dealing with complaints is often a close colleague of the person who is being complained about. Not surprisingly, complaints often hit a brick wall.

The college has responded to the current toxic professional culture within surgery with a 21-page action plan. The document “Building Respect, Improving Patient Safety: RACS Action Plan on Discrimination, Bullying and Sexual harassment in the Practice of Surgery” claims to show “RACS’ commitment to dealing with unacceptable behaviours; strengthening surgical education and training; and reshaping the culture of surgery on foundations of collaboration and respect”.

The action plan is difficult to read, let alone understand. It is replete with weasel words. Phrases create an impression that a meaningful statement has been made, when only a vague or ambiguous claim has been communicated.

According to the current President of the Royal Australasian College of Surgeons: “We must make it safe for victims and bystanders to speak up. There must be clear consequences for those whose behaviour is unacceptable.” Unlike the action plan, his statement is clear.

The Royal Australasian College of Surgeons plans to provide education in countering discrimination, bullying and sexual harassment. Once again, the onus is on the victim to take action. However, with better complaints mechanisms, perhaps the victims will now get justice.

The college also plans to change the way surgeons are trained. Current surgical training arrangements provide disincentives for doctors seeking work-life balance to join the surgical profession. The current arrangements favour those without family commitments or with partners who have less demanding careers.

They aim to embrace diversity and foster gender equity. However, simply bringing females into the surgical boys club will not change this culture. Changing the toxic culture among surgeons requires structural change.

Respect living wills

Letter, The Age

I arrived at an aged care facility recently to find a fire truck, 2 Mobile Intensive Care Unit Ambulances (MICA), a paramedic motorcycle and an ordinary ambulance. The flashing lights heralded the death of a 94-year-old resident. The nurse in charge had dialled 000 despite explicit written instructions that the resident not be resuscitated. Residents of aged care facilities are encouraged to make living wills. These advance directives allow residents and their families to state their wishes for end-of-life medical care. These living wills are meaningless unless health care professionals respect our wishes.

Sarah Russell, Northcote

Too quick to prescribe

pills

Letter, The Age

I am the medical power of attorney of my 91-year-old mother, who lives in an aged-care facility. She was recently reviewed by a psychogeriatrician, who prescribed a new drug to slow down the progression of Mum’s dementia, despite the fact her dementia is progressing slowly without this drug. Instead, I prescribed lifestyle intervention, such as outings and conversation, to improve Mum’s quality of life.

Another doctor was concerned my mother was taking a diuretic without a potassium supplement. I explained that she ate several bananas a week, because they are her favourite fruit. Surely, this is preferable to taking a drug.

Last Saturday, my mother had a fall. The doctor was sure she had not fractured her ribs, but still ordered an X-ray. The only treatment for a fractured rib is rest and analgesia. I cancelled the X-ray and instead prescribed trips to the park in a wheelchair and The Age crossword. With burgeoning healthcare costs, I call on all medical doctors to ask: is that drug or medical test really necessary?

Sarah Russell, Northcote

Greedy son syndrome

Letter, The Age

Financial elder abuse is family violence. Senior Law suggests the contributing factor is ageism rather than gender (Domestic violence victims not just women). However, research shows that women over the age of 80 are most at risk of financial elder abuse, with adult sons being the most common perpetrators.

Some children assume that older women, particularly those who have not been the family’s breadwinner, are unable to manage their own finances. After the father dies, they encourage their mother to appoint a financial power of attorney, often a son. In some cases, the mother is declared legally incapable.

Children with ‘Early Inheritance Syndrome’ feel a sense of entitlement to their mothers’ assets. These impatient children will actively seek ways for their mothers to give them money. They claim: “Mum doesn’t need money, and it’s going to be mine anyway.”

Some greedy children keep their eyes peeled on the Bank of Mum. They curtail her expenses, such as money she spends on holidays, carers and Kingston biscuits. They protect what they see as their entitlement.

The financial abuse of older women is on a continuum of violence towards women. It should be a criminal offence.

Sarah Russell, Northcote

 

 

 

Keeping an eye on the bank of Mum

Australians are living longer and living richer than at any time in our history. The Intergenerational Report predicts that 40,000 people will celebrate their 100th birthday in 2055. Some older women will enjoy their wealth – travelling the world, with their luggage broadcasting that they are ‘spending their children’s inheritance’. Others will live in an aged care facility while their children keep their eyes peeled on the ‘Bank of Mum’.

State Trustees Victoria report ‘For Love or Money: intergenerational management of older Victorians’ assets’ shows that women over the age of 80 are most at risk of financial elder abuse. This research found that adult sons are the most common perpetrators.

Financial elder abuse involves taking or misusing an older person’s money, property or assets. Studies confirm that financial abuse is the fastest-growing type of abuse of older women. So much so that Senior Rights Victoria suggested the terms of reference for the Royal Commission into Family Violence should include elder abuse.

When a father dies, some adult children assume what was once ‘Mum and Dad’s money’ is now their money, not their mothers’. They are not willing to wait for their inheritance until after their mothers die. Children with ‘Early Inheritance Syndrome’ feel a sense of entitlement to their mothers’ assets.

These impatient children will actively seek ways for their mothers to ‘gift’ them money, or will interfere in the management of their parents’ assets to protect what they see as their entitlement. They will keep a close eye on their mother’s assets and curtail her expenses, such as money she spends on holidays and carers.

According to the Office of the Public Advocate, older women are also more likely to be declared legally incapable than older men. This may be due to the fact that women live longer than men. Some children assume that older women, particularly those who have not been the family’s breadwinner, are unable to manage their own finances. After the father dies, they encourage their mother to appoint a financial power of attorney, often a son.

Children with ‘Early Inheritance Syndrome’ make assumptions that devalue the rights of older women.

  1. “Mum doesn’t need money, and it’s going to be mine anyway.”

In cases of financial elder abuse, this is the most common justification given for taking a mother’s money whilst she is alive.

  1. “Mum finds talking about her finances stressful.”

Some children believe that their mother finds discussions about financial issues complex and stressful. This is not only patronising but it also disempowers older women to make choices about how their money is spent.

  1. “Having a large amount of money does not improve Mum’s quality of life.

Most of us take comfort in the security of having savings in the bank. Why are older women different?

  1. “Mum will be no worse off after gifting her money to her children”.

This statement is absurd. By gifting money to their children, the children are better off at the expense of their mother. The less money an elderly woman has, the less money she will be able to spend on herself. 

  1. “Reducing Mum’s income will reduce her fees at the aged care facility”.

Lower fees at the aged care facility means more money for the beneficiaries of the will (i.e. the children). However, many older women may appreciate the care that they receive in an aged care facility, and are happy to pay higher fees for receiving good care.

  1. “Reducing Mum’s income will reduce the amount of tax she needs to pay”

Gifting money to children will result in Mum paying less tax. This may be a good thing for the children, but certainly not for society.

  1. “Mum’s current will cannot be changed”.

Most people change their wills throughout their lives as their circumstances change. Why are older women different? Spending years in an aged care facility may change an older woman’s ideas about how the money is distributed after she dies. She may prefer to give some money to Doctors without Borders, The Lost Dogs Home, or even a kind nurse at the aged care facility. This is her decision, not her children’s.

  1. “By gifting money to the children, this gift reduces their children’s loans and interest payments on these loans.” 

Should middle-age professional people expect their elderly mother to assist them to manage their ‘lifestyle choices’?

Financial elder abuse may begin with the best intentions – with an elderly woman asking a child to act as her financial power of attorney. This can quickly progress to a sense of entitlement, particularly when adult children have mortgages or debts.

There is little reliable data on the extent of financial elder abuse. It is often a silent crime – unreported and unacknowledged. Although the banking industry has introduced initiatives to help prevent this silent crime, financial elder abuse remains difficult to police.

Published in Online Opinion