Elderly Patients' Rights in End-of-Life Care

1
Elderly Patients' Rights in End-of-Life Care
Decisions Domestic/Abroad

• Sooyoun Han, PhD, MSW, Founder
• CARE RIGHTS (Republic of Korea)

2
Increase in World Ageing and International
Migration

• The older population is itself ageing. Globally,
  the share of older persons aged 80 years or
  over (theoldest old) within the older
  population was 14 percent in 2013 and is
  projected to reach 19 percent in 2050.
• If this projection is realized, there will be
  392 million persons aged 80 years or over by
  2050 more than three times the present number
• (U.N. Department of Economic and Social
  Affairs, 2013)
• The number of international migrants worldwide
  reached 232 million in
• 2013, up from 154 million in 1990. The global
  population of international
• migrants is growing at a rate of about 1.6
  percent per year (U.N. DESA, 2013).
• Globally, there are close to 26 million migrants
  aged 65 and over. These
• older migrant represent 11 of the total
  migrant population (U.N.
• Population Division, 2013)

3
Figure 1 Age Distribution Among International
Migrants, 2013
4
Increase in Ageing and Migration in South Korea

• South Korea has the fastest growing ageing
  population in Eastern Asia.
• In 2011, 2,128 people reverse migrated to South
  Korea from the U.S, which
• marked the largest population of reverse
  migrators to South Korea that year.
• (Korean Ministry of Foreign Affairs, 2012).
• 95,234 American Nationals aged 60 years or older
  entered South Korea in 2011 14,708 of them
  remained in the country for three or more months
• with registered foreigner status from the U.S.
  (Han, 2012).

5
Figure. 2. International Migration, 2013
6
Identified Problems in Elderly Patients EOL
Care Decisions, Domestic/Abroad in South Korea

• Multidimensional Understanding about Elderly
  Patients
• Autonomy by Family Norms on EOL Care Decisions
• Cultural ideas and expectations for family
  caregiving play a crucial role
• in the EOL care decision making process
  Many Asian countries consider
• these discussions taboo and filial impiety.
• Often, elders do not understand the concept of
  patient autonomy. Thus, EOL
• decisions are relegated to family caregivers
  (Kwon, 2010).
• Korean healthcare staffs rarely discuss issues
  related to EOL care directly
• and privately with the elderly patients. In
  fact, they are often excluded
• entirely from the EOL decision making process
  (Han Lee, 2013).

7
Identified Problems in Elderly Patients EOL Care
Decisions, Domestic/Abroadin South Korea

• 2. Lack of
  Health Care Legislation Regarding EOL Care
  Decisions
• Lack of Health Care Legislation promoting
  Advance Directives raises
• the risk of immature EOL decisions that could
  result in healthcare deficits
• such as neglect, abuse, and discrimination for
  elderly patients EOL care
• decision, domestic/abroad.
• Differences in legal systems and health
  insurance plans among countries in
• EOL care decision results in lack
  coordination in upholding the
• Emergency Medical Service Act and utilizing
  the Emergency Service Fund
• (ESF) to aid domestic and foreign elderly
  patients.

8
Contingent Disparities to Domestic/Abroad Elderly
Patients and Their Family Caregivers in EOL Care
and Decision

• 1. Violation of Human Rights
• Older persons should receive medical care only
  upon their free and
• informed consent, and may freely withdraw
  consent at any time.
• (Recommendation CM/Rec(2014)2, Council of
  Europe).
• Domestic and foreign elderly patients are too
  often deprived of their rights to informed
  consent during EOL care decision in South
  Korea.
• Domestic and foreign elderly patients desire to
  refuse aggressive
• life-sustaining treatments may not be fully
  preserved if they are unable to
• make EOL decisions at the time of service in
  South Korea.

9

• Most elderly patients, domestic or foreign, in
  South Korea are often
• administered unwanted aggressive
  life-sustaining treatments without
• protection from culturally-designed, advanced
  EOL decision making process
• that makes available and promotes pain-free
  and comfortable hospice care.
• 
  Video Clip

10
Contingent Disparities to Domestic/Abroad Elderly
Patients and Their Family Caregivers in EOL Care
and Decision

• 2. Health Care Expenditure for Unmet Needs
• The Korean Emergency Service Fund (ESF) expends
  one third of the total
• budget for emergency care to patients from
  abroad, who are also funded
• partially by travel insurance and private
  medical insurance. However, unmet
• needs still remain due to insufficient
  development of health care protocol in
• EOL care decision making.
• Of U.S. Medicare decedents (85 years of age),
  who required Intensive Care
• Unit/Coronary Care Unit services in their last
  30 days of life varied by race
• White (21.3), Black (26.2), and Other
  (27.9).
• Percentage of Medicare decedents (age 85) who
  died in an
• in-patient/hospital setting varied by
  ethnicity Asian (43.6), Hispanic
• (41.1), Non Hispanic Black (38.0), and
  Non-Hispanic White (31.1).

11

• Figure.3 65 Medicare Decedents Place of Death
  by Ethnicity (U.S.)

• Figure.4. Preliminary Data on Place of Death by
  Country in E.U.

Sources United States Weizen SMS et al. (1)
England and Wales Office of National Statistics
2000 Switzerland extrapolations from Federal
Statistics 1985 France INSERM 1999.
Netherlands Central Office of Statistics in the
Netherlands, 2000, M Ribbe, personal
communication. Germany Thomas Schindler,
personal communication. Ireland Julie Ling,
personal communication. Note Data from different
countries are collected in different ways and
sometimes not at all. This has limited the
comparison that can be drawn, but highlights
the need for health care systems across Europe to
begin to collect this information routinely. Some
15 of deaths in the Netherlands also occur in
residential homes for the elderly, and these are
not included in the graph above.
12
Contingent Disparities to Domestic and/or Abroad
Elderly Patients and Their Family Caregivers in
EOL Care and Decision

• 3. Unsolved Emotional Complications and
  Bereavement
• Korean family caregivers who made EOL decisions
  to admit their elderly
• parents and/or spouses into Hospice programs
  experienced tremendous grief,
• loss, guilt, anger, and confusion with regard
  to their decision on behalf of
• their parents and/or spouses (Han Kim,
  2013).
• In South Korea, social workers in a healthcare
  settings such as LTC practices,
• help elderly patients and their family
  caregivers in the EOL decision making
• process but lack structured education and
  training in specific communication
• skills related to EOL care decision making
  (Han, 2014).

13
Murder of A Lineal Ascendant2013Case
citation Uijeongbu District Court, 392.

• Defendants Son, Daughter, and Wife of the Victim
• Victim Father and Husband to the Defendants
• Case The victim got diagnosed with terminal
  stage brain cancer in January of 2013. His
  daughter, one of the defendants, was his primary
  caregiver who covered his medical cost (300) and
  provided for the rest of the family with her
  monthly income (1,500) ever since. The victim
  continually requested his death to eliminate his
  terrible pain. The daughter conspired with her
  brother to grant the victims wish. The victims
  wife was present as witness.
• Clauses
• Article 250 - Section 2 of Criminal Code
• Whoever kills ones own or
  spouses lineal ascendants shall be
• sentenced to death or more
  than seven years in prison
• Article 30 - Criminal Code
• When two or more persons
  jointly committed a crime, a self shall
• be punished for the sin of
  the principal offender
• Verdict Son Daughter were found guilty and
  sentenced to serve 3 years and 6 months in
  prison. Wife was found guilty and sentenced to
  serve 1 year and 6 months in prison.

14
International Enactment for EOL Care Decision
Act about Domestic/Abroad Elderly Patients
Rights

• Directions in the Madrid Plan of Action on Ageing
  
• Advancing Health and Well-Being into Old Age
• Universal and equal access to health-care
  service for elderly patients as well as their
  family caregivers in their EOL care and decision
• Care Rights provides Hospice Shelter Program to
  domestic and foreign elderly patients during
  their EOL care decision making process to
  promote comfortable, and culturally-designed
  care.
• In diaspora communities,
  hospital ICUs, homeless shelters, prisons and any
  setting where human rights in their final stages
  of life may be deprived, we should take extra
  concern to protect them.

15
International Enactment for EOL Care Decision
Act about Domestic/Abroad Elderly Patients Rights

• Directions in the Madrid Plan of Action on
  Ageing(2002)
• Advancing Health and Well-Being into Old Age
• Training of care providers and health
  professional for elderly patients in their EOL
  care and decision
• Care Rights provides Psycho-Educational
  Intervention Program for domestic and foreign
  elderly patients and their family caregiver in
  EOL care decision with evidence-based,
  cost-effective and culturally-designed.
• Psycho-Educational
  Intervention Program improves family caregivers
  understanding and their ability to navigate the
  EOL decision making process (Han et al, 2013).

16
References

• U.N. Department of Economic and Social Affairs
  (2013). World Population Polices 2013. New York
  U.N.
• U.N DESA. (2013). World Population Ageing 2013.
  New York U.N. http//www.un.org/en/development/de
  sa/population/publications/pdf/popfacts/popfacts_2
  013-4.pdf
• Korean Ministry of Foreign Affairs (2012)
  Diplomatic White Paper. www.mofa.go.kr/ENG/pol
  icy/whitepaper/index.jsp?menum_20_160
• Han, S. B. (2012, 05 03) Rush of reverse
  migration due to expensive medical cost in
  abroad. Seoul Newspaper http//www.seoul.co.kr/
  news/newsView.php?id20120503010010.
• Kwan, Iro Bae, H.A. (2011). A Narrative
  Analysis of Ethical Issues Regarding End-of-Life.
  J of Korean Medicine Ethic, 14(2). 157-170.
• Han, S. K. Lee, H.J.(2013). A Discussion on
  Elderly Patients and their Family Caregivers
  Decision Making for Life Sustaining
  Treatments. GRI, 15(2).71-91.
• Council of Europe (2014). The Promotion of Human
  Rights of Older Persons, Recommendation
  CM/Rec(2014)2.
• Federal Interagency Forum on Aging Related
  Statistics.(2013). Older Americans 2012 from
  http//www.agingstats.gov/agingstatsdotnet/Main_Si
  te/Data/2012_Documents/docs/EntireChartbook.pdf.
• 9. WHO (2004). The Solid Facts, Palliative
  Care from
• http//www.euro.who.int/__data/assets/pdf_f
  ile/0003/98418/E82931.pdf?ua1
• 10. Song, K.M., Kim, Y. S., Lee, Y. H. (2008).
  Legalistic Study of the Subrogation Payment in
  Emergency Medicine. The Korean Study of
  Law and Medicine, 9(2), 139-179.
• 11. UN, Economic and Social Council (2012).
  Report of the UN High Commissioner for Human
  Rights. Substantive Session
• 12. Han, S.K. Kim, T.H.(2013).Desperate Family
  Caregivers and EOL Decision of Elders with
  Dementia in S. Korea. AAA Annual
• Conference, Chicago presented in the Round
  Table Discussion.
• 13. Han, S.K.(2014). A Study of Social Workers
  Understanding of EOL decision and of their Role
  in Life Sustaining Treatment
• Decision Making of Elderly Patients and
  their family caregivers in LTC. GRI (under
  reviewed).
• 14. Han, S.K., Kim, John, Han, Jason, Lee, H. J.,
  Park, S.Y.(2013). The Effects of an
  Psycho-Educational Intervention Program on Family
  Caregivers
• Understanding about EOL decision for Korean
  Immigrant Elderly with Dementia K. J of Social
  Welfare Research, 35. 1-23.