Raymond J. Hanley

Predicting Elderly Nursing Home Admissions: Results from the 1982-1984 National Long-Term Care Survey

Predictors of elderly nursing home admissions were identified using the 1982-1984 National Long-Term Care Survey. The authors found age and health factors were important predictors. Gender was not a significant predictor for disabled elderly admissions when controlling for other variables, even though women constitute the vast majority of nursing home residents. Three of four measures of informal support availability and use were not significantly related to nursing home admission by the disabled. Income and asset wealth were also nonsignificant predictors of institutionalization by the disabled community population.

Will Paid Home Care Erode Informal Support

One of the main barriers to the expansion of paid home care for the chronically disabled is the fear that policymakers have that it will cause friends and relatives to curtail their informal caregiving efforts. Using the first wave of the National Long-Term Care Survey, we examine whether the amount of paid home care used by disabled elderly persons had a significant influence on the amount of informal support they were receiving. Results from a two-stage least squares regression analysis suggest that the amount of informal home care received was not significantly affected by the level of formal care. This conclusion held for subgroups of formal care users most likely to exhibit substitution: those without cognitive problems, the disabled elderly with above average income, and persons who lived alone. Even the more severely disabled elderly, who are the target of most proposals to expand paid home care, did not substitute paid care for unpaid. Thus, our study suggests that an increase in paid home care will not erode informal support.

Use of Paid Home Care by the Chronically Disabled Elderly

Determinants of paid home care use among the chronically disabled elderly were analyzed using the 1982 National Long-Term Care Survey. In 1982, about one quarter of the elderly disabled had a paid home care provider. Using logistic regression, the analysis found the predictors of any use of paid home care were age, sex, marital status, number of daughters and sons, ADL problems, a prior nursing home stay, an overnight hospital stay, income, home equity, and Medicaid enrollment. Using ordinary least-squares regression, the study also identified predictors of the amount of formal home care used in the last week. For elderly with a paid home care provider, greater age, disability level, not being married, fewer daughters, and cognitive impairment signal significantly more use.

THE CONNECTICUT MODEL FOR FINANCING LONG-TERM CARE: A LIMITED PARTNERSHIP?*

and hallowed what might otherwise be called greed), and it is evident that racism and sexism infect America and, therefore, must influence its judgments. Many trial lawyers will tell you that blacks, women, Hispanics, or persons with accents are less likely to be believed than are their American-born, white, male counterparts. That some white juries often treat minorities differently than they would those belonging to the white middle class is well known and, regrettably, makes the outcome of the Rodney King case less than a startling surprise. Often prejudice (or self-interest) is far from overt; it is given a veneer of acceptability by hiding the action under another name. Labeling persons as depressed or incompetent (and, therefore, unable to make proper decisions) may serve as such a veneer. As the authors point out, four previous studies have already cast doubt on the supposedly invariably negative effect of depression on decision-making. Still, no conclusions for practice can be drawn. The fact that firm conclusions require more than a handful of studies to be implemented into accepted practice is as true for ethical decisions as it is for scientific ones.8 “Facts” are derived from a careful study of many similar cases and are then subjected to statistical analysis. Such information is crucial when it comes to assessing the “risk” which any intervention (chemical, surgical, or ethical) may pose. This critical knowledge is not in itself sufficient for planning a course of action in a specific patient. A plan for a course of action must apply such data to the particular situation posed by a particular patient at a particular time. When this is repeatedly done in a thoughtful manner, it may form the grounds for even sharper distinctions. We may, for example, be able to identify specific groups at greater or lesser risk. Anecdote (or preliminary studies) are not a safe or proper guide to behavior? Continuing life-sustaining treatment in the face of a patient’s clear wish to the contrary is, at the very least, problematic. Overruling a patient’s clearly expressed wish may not be the ethically proper thing to do. As the authors indicate, not only is it ethically problematic to continue invasive (and equally so, I would argue, non-invasive) life support against a patient’s clearly expressed wish, doing so could very much help to deepen depression. After all, having one’s wishes ignored and feeling utterly powerless to direct one’s fate are very likely to make one more depressed. At the very least, the role of depression in determining patients’ decisions regarding life-sustaining therapy needs to be carefully studied. As it now stands, the role of depression in a patient’s decision-making capacity is unclear; it may be that we are asking too broad a question, akin to when we asked whether coronary artery bypass surgery prolonged life. It was only when we found the question we asked was too broad and that sub-groups within the concept ”coronary disease“ needed to be delineated that proper answers emerged. Perhaps this is also the case here. For now, we will undoubtedly continue to allow the presence of depression to influence us, but we will do so less easily than before. Moreover, when we apply what we have learned and will learn, we will need to be sensitive to the individual patient’s “work of art,” as Eric Cassel so eloquently put it.” No matter how good a painter, Van Gogh could not successfully complete a Rembrandt self portrait, nor could Mahler authentically finish Schubert’s “Unfinished.” The best we can do is to try hard to understand and remain true to each other’s style. Physicians and ethicists must be sensitive to the way in which a person envisions and constructs the intimate art form which is his/her life and must help each one complete it in his/her own particular fashion. When decisions patients make seem inconsistent with previous styles, when the way they paint or compose seems out of character and depression is present, there may be some validity in overriding their wishes. But when patients‘ decisions seems consistent with their works of art, depression alone should not be allowed to veto what otherwise would appear to be an authentic wish. Lee and Ganzini’s paper opens a fertile field for investigation. While it indicates that depression may play a role in a patient’s eventual decision about using life-sustaining therapy, it indicates that, at most, such a role modifies these judgments. It does not support the veto power which we have allowed depression to have. The paper points to the sad fact that none of us is free of some sort of prejudice. While pre-judgment undoubtedly is inevitable (none of us is unbiased or enters situations entirely without preconceived notions), acting on it is another matter. Our opinion about the effect of depression on patients’ attitudes about life-sustaining therapy may well prove to be wrong.

Financing and Use of Long-Term Care for the Elderly

Perhaps no other part of the health-care system generates as much frustration as does the organization and financing of long-term care (LTC) for the elderly. The disabled elderly and their families confront a fragmented delivery and financing system, a relative lack of noninstitutional services, long waiting lists for institutional placement, mediocre-quality care, and financing hardship (Vladeck, 1980). Public financing, primarily through Medicaid, is perceived as both overly expensive and inadequate.