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2 - Ethical and Socioeconomic Considerations |
47
Accountable Care Organizations (ACOs), a key
feature of the ACA, remain.
46
Other Health Insurance Options
Two common options available to seniors when
selecting private health insurance are fee-for-
service insurance and managed care plans:
HMOs or preferred provider organizations
(PPOs). Eligibility for private health insurance
usually requires a medical examination to prove
the patient is insurable, and the insured patient
pays out-of-pocket premiums and deductibles
for healthcare services. Some employers provide
health insurance, which includes prescription
drug coverage for vested retirees. The Depart-
ment of Veterans Affairs (VA) provides health-
care to veterans, dependents, and survivors
according to eligibility; nearly 45% of veterans in
the United States are over the age of 65 years,
and 9.73 million veterans are enrolled in the
VA healthcare system.
47
A joint Medicaid and
Medicare program known as PACE (Programs
of All-inclusive Care of the Elderly), is available
in many states to allow seniors who need more
care to remain in the community and receive
healthcare services at home, if they reside in the
service area of a PACE organization and meet
the eligibility criteria.
Challenges of Existing Models of
Healthcare Financing
The geriatric population, those 65 years of
age and older, accounts for 36% of all hospital
stays, 49% of all days of care in hospitals, and
consumes almost one-third of the total U.S.
healthcare expenditures.
48
Although geriatrics
compose about 12% of the U.S. population,
they account for 34% of all prescription medica-
tion expenditures and 25% of OTC medication
usage.
49
An estimated 91% of the U.S. popula-
tion aged 65 and older has an annual prescrip-
tion drug expense. In 2013, there were over 35
million Medicare Part D enrollees, an increase of
12% from 2012.
50
The existing models of U.S. healthcare
financing ultimately limit the individual patient’s
autonomy in making choices related to health-
care. The challenge is in achieving a balance
between the access to healthcare and the
provision of effective and affordable healthcare.
Private health insurance plans commonly have
prescription drug benefits, but these may be
rigid in requiring the patient to purchase main-
tenance prescriptions from specific pharma-
cies or from mail-order pharmacies, use formu-
laries with associated tiered copayments for the
prescribing of brand name drugs over generic
drugs, and/or require prior authorization from the
third-party payer for use of certain brand name
drugs or drug classes.
When choosing between independent
community pharmacies and chain community
pharmacies for pharmacy services, ambulatory
geriatric patients often price shop for prescrip-
tions in a competitive market made
more wide-
spread by the recently implemented inexpensive
generic offerings at chain pharmacies. When
seniors are admitted to long-term care settings,
either an assisted living facility or a skilled nursing
facility, their choice of a provider of pharmacy
services may be limited to those that can provide
the medications in the packaging system used
by the facility and/or those pharmacy providers
who can provide the federally mandated consul-
tant pharmacy services to the residents of the
facility. Pharmacy services for residents of long-
term care settings are further complicated by
the increasing use of formularies to manage
prescriptions and control costs. Complications
arise from the need to educate prescribers on
the use of formularies and state pharmacy regu-
lations regarding medication substitution issues.
The emergence of managed care as a major
healthcare force affecting older persons raises
its own set of ethical issues. Whereas managed
care offers older persons some attractive advan-
tages, its propensity to reduce access to choice
of care can be a major threat to healthcare for
the more frail older patients. Geriatric patients
are prime targets for efforts aimed at rationing
healthcare because they consume dispropor-
tionately large amounts of medical care and
because they are seen as having already lived
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48
| Fundamentals of Geriatric Pharmacotherapy
their lives. Within the efforts to limit spending
on older people, subtle approaches have been
used and are cloaked in ethical concepts. Policy
issues largely address questions of access and
coverage, but these can be influenced by an
individual clinician’s beliefs about what elements
of care are appropriate for older people. These
beliefs, in turn, can reflect stereotypes and,
therefore, ethical issues arise at the bedside
when decisions about initiating or continuing
treatment are made.
38
The geriatric patient is often in a state of
dependency, and there is disagreement on the
value of a life lived with some level of depen-
dency. If the level of dependency is the primary
outcome of healthcare, this implies that those
who are dependent are no longer important to
society. Much attention has been given to the
money spent on healthcare in the last year of life.
Costs related to healthcare increase when death
approaches; the costs during the last month
of life represent approximately 40% of the total
costs for the last year of life.
51
Approximately
28% of the Medicare budget goes to the 5% of
Medicare patients who die each year.
52
In the provision of pharmaceutical care for
geriatric patients, pharmacists have an obliga-
tion to work with patients, their caregivers, and
third-party payers to ensure that older patients
receive the most appropriate medications to
manage their health problems. Pharmacists
should be prepared to discuss both the benefits
and the limitations involved in obtaining afford-
able prescription medications, including the
use of OTC medications in lieu of prescription
medications, generic drugs, pill-splitting, tiered
copayment benefit plans, prescription drug
plans, mail-order pharmacies, Internet pharma-
cies, and prescription assistance programs from
State Pharmacy Assistance Programs (SPAPs)
community coalitions, nonprofit organizations,
and the Pharmaceutical Research and Manufac-
turers of America (PhRMA).
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2 - Ethical and Socioeconomic Considerations |
49
C 1: S N F
SCENARIO ONE
Subjective:
SS is a 90-year-old female who has been a resident of a skilled nursing facility for 8 years.
Past Medical History:
Late-stage Alzheimer disease; heart failure; receives nutrition via a nasogastric tube; confined
to bed; occasional urinary incontinence. Within the past year, SS has been hospitalized four
times due to the heart failure.
Medications:
Donepezil 10 mg at bedtime, aspirin 81 mg once daily, lisinopril 10 mg once daily, HCTZ
12.5 mg once daily, acetaminophen 650 mg every 6 hours as needed for pain (all medications
are administered via the nasogastric tube).
Allergies:
NKDA.
Social History:
BK (SS’s daughter) is a court-appointed guardian for SS and has had the physician sign a DNR
order.
Family History:
Noncontributory.
Objective:
BP 126/76, P 76 BPM, RR 24, oral T 97°F, Ht 5´1˝, Wt 118 lb.
Physical Examination:
Chest examination revealed dyspnea, productive cough, rhonchi.
Labs:
Sputum gram stain reported as: >25 WBC/hpf, <10 epithelial cells/hpf, many Gm (+) cocci in
pairs. C&S reported as Mycoplasma pneumonia. Sensitive to erythromycin and azithromycin.
Assessment:
SS is a 90-year-old female with community-acquired pneumonia, cardiac risk factors, poor
nutritional status, occasional urinary incontinence, and poor cognitive status. Signed DNR order
is in the medical record.
Intervention:
Forty-eight hours after the above assessment was written, RT, the consultant pharmacist for
the facility, is completing the monthly drug regimen reviews. During the chart review for SS,
RT noted the patient’s diagnosis of community-acquired pneumonia with no order for antibiotic
therapy. When RT questioned the nurse regarding the lack of an order for an antibiotic, the
nurse responded that because the patient is DNR, “No antimicrobial therapy is warranted in
this situation.”
Plan:
Contact physician for antibiotic order, as patient is not in cardiac or respiratory arrest.
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| Fundamentals of Geriatric Pharmacotherapy
Rationale:
1.
The court-appointed guardian for SS has had the physician sign a DNR order. At this
point, the patient is not in cardiac or respiratory arrest, so an antibiotic should be
ordered.
2.
The physician has a professional responsibility to SS to order an antibiotic to treat the
pneumonia. The pharmacist has a professional responsibility to contact the physician
and obtain an order for an antibiotic to treat the pneumonia.
3.
The ethical issues raised in this scenario include respect for patient autonomy (right
to self-determination) and surrogate decision making, beneficence (help others and
promote patient welfare), and nonmaleficence (at least do no harm). If the pharmacist
did not follow up with the physician to obtain an order for an antibiotic, the pharma-
cist would not respect the surrogate decision and would place SS in harm. Compare
this ethical dilemma to the following scenario.
SCENARIO TWO
Subjective:
SS is a 90-year-old female who has been a resident of a skilled nursing facility for 8 years.
Past Medical History:
Late-stage Alzheimer disease; heart failure; receives nutrition via a nasogastric tube; confined
to bed; occasional urinary incontinence. Within the past year, SS has been hospitalized four
times due to the heart failure. Within the past 3 months, SS has developed recurrent pneumo
-
nias with subsequent deterioration after each one (a total of four) pneumonias, each requiring
hospitaliza
tion in addition to the four episodes with heart failure exacerbation.
Medications:
Donepezil 10 mg at bedtime, aspirin 81 mg once daily, lisinopril 10 mg once daily, HCTZ
12.5 mg once daily, acetaminophen 650 mg every 6 hours as needed for pain (all medications
are administered via the nasogastric tube).
Allergies:
NKDA.
Social History:
BK (SS’s daughter) is a court-appointed guardian for SS and has had the physician sign a DNR
order.
Family History:
Noncontributory.
Objective:
BP 126/76, P 76 BPM, RR 24, oral T 97°F, Ht 5´1˝, Wt 118 lb.
Physical Examination:
Chest examination revealed dyspnea, productive cough, rhonchi.
Labs:
Sputum gram stain reported as: >25 WBC/hpf, <10 epithelial cells/hpf, many Gm (+) cocci in
pairs. C&S reported as Mycoplasma pneumonia. Sensitive to erythromycin and azithromycin.
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2 - Ethical and Socioeconomic Considerations |
51
Assessment:
SS is a 90-year-old female with community-acquired pneumonia (fourth pneumonia in 120
days with subsequent deterioration following each case), cardiac risk factors, poor nutritional
status, occasional urinary incontinence, and poor cognitive status. Signed DNR order is in the
medical record.
Intervention:
Forty-eight hours after the above assessment was written, RT, the consultant pharmacist for
the facility, is completing the monthly drug regimen reviews. During the chart review for SS,
RT noted the patient’s diagnosis of community-acquired pneumonia with no order for anti-
biotic therapy. When RT questioned the nurse regarding the lack of an order for an antibiotic,
the nurse responded that the physician stated, “No antimicrobial therapy is warranted in this
situation.” She further describes a consultation between the physician and the court-appointed
guardian for SS (the daughter) where the daughter stated that she understood her mother
will not return to her previous level of functioning. The daughter stated that her mother would
not wish to continue with multiple infections and poor quality of life. The surrogate decision is
made to place SS in hospice.
Plan:
Withhold antibiotics. Ensure pain and other symptom management is optimized.
Rationale:
Respect patient autonomy and withhold antibiotics. Ensure beneficence by ensuring patient is
kept comfortable.
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| Fundamentals of Geriatric Pharmacotherapy
C 2: C P
Subjective:
WW is a 78-year-old male retired from the telecommunications industry. He lives in his private
residence with his wife of 56 years. He has no current health-related complaints.
Past Medical History:
Type 2 diabetes, hypertension, hyperlipidemia, depression, osteoarthritis, and macular
degeneration.
Medications:
Pioglitazone 15 mg every morning, metformin 1000 mg twice daily, losartan 25 mg twice daily,
furosemide 40 mg once daily, ezetimibe/simvastatin 10/40 once daily at bedtime, celecoxib
100 mg twice a daily, venlafaxine XR 75 mg every morning, aspirin 81 mg once daily, Ocuvite
once daily.
OTC Medications:
Multivitamin (senior formula) once daily, meclizine 25 mg as needed, calcium carbonate
500 mg as needed, docusate sodium 100 mg twice daily, fish oil 1000 mg twice daily, biotin
1000 mcg once daily, garlic 1000 mg once daily, purchases diabetic supplies to check blood
glucose four times a day with a glucometer.
Allergies:
Penicillin, radioactive dyes.
Social History:
Negative for tobacco and alcohol; receives Medicare Part D benefits.
Family History:
Unknown.
Objective:
BP 166/78 (on self-check BP machine in the pharmacy), Ht 6´2˝, Wt 196 lb.
Physical Examination:
WDWNWM in no acute distress.
Labs:
Not available; WW stated that at his last physical (2 months ago) “Everything was A-OK!”
Assessment:
WW is 78-year-old male with elevated blood pressure who presents at the pharmacy counter
and asks to speak with the pharmacist about the cost of his medications.
Plan:
1.
Review WW’s patient profile and complete a medication therapy management plan
for WW.
2.
Discuss with WW available alternatives for obtaining affordable prescription medica
-
tions and reducing medication costs.
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2 - Ethical and Socioeconomic Considerations |
53
Rationale:
1.
The older patient is frequently on a complicated medication regimen that often
includes OTC products and dietary supplements. Pharmacists should develop MTM
plans especially for geriatric patients. Pharmacists should discuss these medication
therapy plans with patients to ensure they understand the indication and directions
for use of each medication in their regimen.
2. Pharmacists should work with elderly patients to ensure that those enrolled in Medi-
care Part D prescription drug plans are enrolled in one with a formulary most appro-
priate for their medication profile; generic alternatives are being dispensed when
available; the most appropriate tiered copayment drugs are prescribed; patients
are receiving medications from mail-order pharmacies, if appropriate; patients are
informed of the advantages and cautions of ordering prescription medications from
Internet sources; prescription assistance plans available from community coalitions,
nonprofit organizations, and PhRMA are maximized for the patient’s benefit.
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| Fundamentals of Geriatric Pharmacotherapy
C S
The tenets of biomedical ethics are important
to the provision of healthcare and pharmaceu-
tical care for the geriatric patient. Pharmacists
respect patient autonomy by allowing patients to
exercise their right of self-determination; display
nonmaleficence when they act to prevent harm
for the patient; display beneficence when they
act for the good of the patient; and demonstrate
justice when they allocate goods and services to
their patients in an equitable manner.
Communication and decision making are
important in providing healthcare for geriatric
patients. Health care practitioners in general,
and pharmacists specifically, should strive for
effective communication with geriatric patients
and assist them in having their personal choices
regarding healthcare decisions made known
and accomplished. Although a major benefit of
managed care is that of shared risk, in reality
the current healthcare system has the potential
to limit access to healthcare choices for geriatric
patients.
Through the provision of accessible, conve-
nient, confidential, and appropriate pharma-
ceutical care, the pharmacist can contribute
to the resolution of healthcare disparities in the
geriatric patient population. It is the professional
responsibility of pharmacists to serve as patient
advocates to ensure that these patients receive
the pharmaceutical care to which they are enti-
tled and that they desire.
S-A Q
1. What is the difference between a living will
and a durable power of attorney for health-
care?
2. How do informed consent, privacy, and
confidentiality affect decision making in
geriatric patient care settings?
3. What constitutes life-sustaining therapy?
4. What is the difference between palliative
care and hospice care?
5. How do socioeconomic issues contribute
to healthcare disparities within geriatric
patients, specifically in relation to medica-
tion adherence?
6. What are the differences between Medicaid
and Medicare in terms of financing, eligi-
bility, and benefits?
7. What options are available for geriatric
patients to obtain affordable prescription
Clinical Pearls
• A geriatric patient who refuses aggressive (and expensive) chemotherapy for treatment
of advanced stage breast cancer with the desire to preserve her children’s inheritance
is exerting personal autonomy in decision making. A clinician must defer to the patient’s
wishes to honor the ethical principle of autonomy even if he or she disagrees with the
patient’s decision.
•
When considering the risk-to-benefit ratio of a medication with potentially severe
adverse effects (e.g., aspirin for myocardial infarction prophylaxis in a frail elderly
patient), the pharmacist should take into consideration the patient’s remaining life
expectancy, the time required to obtain benefit from the medication, the goals of care,
and the treatment targets.
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2 - Ethical and Socioeconomic Considerations |
55
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