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Lessons On Aging From Three Nations, Volume II: The Art of Caring for Older Adults

Sara Carmel, Carol A. Morse, and Fernando M. Torres-Gil (Editors)
Baywood Publishing Company (2007)
ISBN 9780895033703
Reviewed by Alma H. Bond for RebeccasReads (1/08)

While the first volume of “Lessons on Aging From Three Nations” focuses on aging and caretaking, the second volume, “The Art of Caring for Older Adults,” concentrates on the challenges and concerns for families, policymakers, and governments in caregiving and end-of-life issues. This book affirms the philosophical belief that people joining forces can achieve great things that one person alone is unable to do. As in Volume 1, the editors and authors hope to provide clues and suggestions for future research, policies, and practices in the comparative study of global aging.

It is widely known that the population of the world is aging, but challenges caused by this burgeoning phenomenon are less well understood. “The Art of Caring for Older Adults” compares treatment of the aged in three countries and focuses on caregiving, family care, and end of life in each of them. The three countries vary in many ways; therefore, how they respond to the problems of aging naturally differs. But all face similar issues in terms of needs, conflicts, difficulties that need to be resolved, and possible solutions. These findings should prove useful to nations throughout the world.

In the introduction, coeditor Carol A. Morse compares the treatment given the aging in the United States, Israel, and Australia (p. 1). She comes to the conclusion that the picture is very similar in all three countries, where the number of people age 80 or beyond who achieve a healthy and well older life is increasing over time. As many more people survive to an advanced age, two generations of the elderly often must be taken care of by the same family. In addition, many women now have full-time careers outside the home. As a result, the old ways of caring for the elderly no longer suffice, as fewer and fewer people willingly take on the burden of family caretaker. Hence, Morse states, “In the years ahead, the governments must find different ways to provide financial compensation for caregivers through tax relief, income support, and indexed pension benefits” (p. 2). She suggests that the situation “requires a move towards a collaborative approach between consumers and workers to replace the paternal custodial model” (p. 3).

Esther Iecovich, in “The Interface between Family Responsibility and State,” speaks of the rapidly growing older population in Israel. She states (p. 7), “A highly developed system of health care, improvements in nutrition and quality of life, and a decrease in fertility rates have resulted in an increased number of elderly people who are infirm, disabled, and dependent upon others.” As the number of older people grows, the less their families will be able to provide adequate care for them. Iecovich questions what solutions family and society can provide to meet the growing needs of this swiftly expanding population. She proposes that adult grandchildren play a more active role in caring for elderly grandparents and aging parents. Social networks, in which volunteers play an increasing role, more formal services, and community care including day care, must become more significant factors in supplementing family care. She also suggests expanding civil service for those individuals not serving in the army to provide such services as home care and surveillance for the aging.

Cheryl Tilse, Jill Wilson, and Deborah Setterland have some interesting things to say about recent developments in Australia in “Residential Care: Informed Choices,” which in many ways can serve as a model for other societies. According to the authors (p. 38), care of the elderly in Australia is now characterized by increased community services that support people in their own homes. The structural reform policy passed by the Australian government in 1997 sought to enhance choice in residential care by the development of a wider range of care options, greater community responsibility, policies of aging that link residential care to resident needs, and the development of outcome standards that include choice as a key aspect of residents' rights. In Australia, contrary to practice in the United States, entry to residential facilities is not dependent on the capacity of the patient or his or her family to pay for services but is subsidized by the government. The reform of residential care is characterized by a move away from the medical model to policies promoting resident-focused care. The authors (p. 40) quote Peace, Kellaher, and Willcocks (1997) to the effect that the changed approach in Australia is founded on an explicit recognition of the rights of residents and is supported by philosophies that recognize adulthood and citizenship. We in the United States could take a page from the Australian book.

Care for the elderly in Israel, according to David Galinsky in “New Demands on Education and Training for the Care of Old People,” is not doing as well (p. 59). “Studies indicate… that care of the elderly in Israel is characterized by fragmentation, lack of coordination of services, and severe budget restrictions.” Galinsky states that these issues have an impact on the education and training of personnel, as programs of formal education are not prepared to meet the challenge. He informs us that research in aging receives no special priority in Israel and suggests that universities as well as medical schools be carefully reviewed in the light of today's shifting attitudes toward care of the elderly (p. 60). He adds that different studies, such as those of Clarfield, Bergman, and Cane (2001), have reached similar conclusions.

In the introduction to Section 2, “The Art of Family Care,” JoAnn Damron-Rodriguez informs us (pp. 63–64) that the huge increase in the number of elderly people challenges the family's historical role in performing caretaking functions. Yet despite the difficulties the new demographics bring about, the family still remains the major support for elders, caring for up to 85 percent in the United States. Many changes have occurred in recent generations, including fewer adult members of families, with those remaining more likely to be engaged in the labor market, wider dispersion of families, the fact that up to four or five generations are now alive at a time, and the increased divorce rate, which can change the relationships of family members to each other. Chapters by Raveis, by Aberdeen, and by Morse and Lau all relate the personal challenges of family care to the need for societal responses (p. 66).

In “In Care and On Call,” Carol A. Morse and Rosalind Lau give us some idea of how widespread family caretaking is in Australia. Incredibly, according to them (pp. 69–70), one in three of the adult Australian population provides some sort of care or assistance to a family member or friend. The prevalence of people needing assistance rises with age until it reaches over 77 percent (!) in the 80-plus age group. Many individuals in need would be unable to remain in their homes were it not for the provision of informal services. Women are the majority of caregivers, providing largely unpaid service, and are most affected by community care policies. They are sometimes aided by formal care provided by government agencies and for-profit and nonprofit organizations. Minority groups of Aboriginal and Torres Strait Islanders and people with lifelong disabilities are particularly ignored in terms of their needs for formal assistance. When no help is available to caregivers, negative effects on their health are apparent.

According to the authors, some general policy implications have emerged during the last 15 years. These include the recognition of the need to improve and expand services, address negative societal attitudes toward caregivers, enhance the recognition of and value of the carer's role and contributions, transform the inequities in caregiving, create better home and community care systems, and alleviate the immediate and long-term burdens of informal caregiving (p. 80).  Although a great deal of progress has been made in bringing about these reforms, there is still much to be achieved.

“The Challenges and Issues Confronting Family Caregivers to Elderly Cancer Patients,” by Victoria H. Raveis, is an excellent source of information for caregivers of cancer patients, and as such, is one of the most valuable chapters in the book. In the United States, almost 60 percent of new cancers and 70 percent of deaths from cancer occur in people over 65. According to predictions of the Census Department, the number of cancer patients 65 and older will double in the next 30 years, while the number of cancer patients 85 or older will increase fourfold. Earlier cancer detection and more effective treatment methods have resulted in a greater number of older adults living for longer periods following a cancer diagnosis. These developments mean that cancer patients and their families are living with the effects of cancer for an extended period; hence, the great value of information such as that given in this chapter.

Cancer caregiving can affect every aspect of caregivers’ lives, including social, professional, and leisure activities, diminishing their ability or willingness to continue their role. Adult married children may find that although their spouse and children initially were sympathetic to their care provision, over time their support wanes as they become resentful of the loss of the caregiver’s time and attention. In addition, caregivers may feel guilty at not being able to devote as much time to their families as they previously had done. In instances when the parent has been otherwise healthy, his or her illness often marks the beginning of a marked role reversal, a life-altering event that can be both challenging and emotionally distressing. Older caretaking spouses are also more vulnerable to the losses caused by the serious illness of their life companions and are more likely to die soon after the death of their mates. As a result of these life-shattering effects of caregiving to the aging, there is a growing national recognition of the importance of providing services and programs to assist families in their care provisions.

One of the most difficult aspects of caregiving is knowing when to let go of the patient and give up one’s identity as friend, spouse, child, or sibling. Susanne Aberdeen in “Letting Go and Holding On” responds to some of these questions, particularly in the case of individuals suffering from dementia, which may last 20 years or more.

Letting go of such patients is a progressive action occurring on many levels. Different victims of the disease may have dissimilar symptoms at various times, depending on the parts of the brain affected. In terms of when to let go of the caretaking role and assign the patient to community care, Aberdeen writes (p. 100) that such a decision is so difficult that some people are never able to make it and simply keep going. She compares their plight to that of a frog in a delightful Chinese proverb to the effect that if you put a frog into a pot of boiling water, it will leap out, but if you place the frog in a pot of cold water and bring it gently to the boil, the frog will stay and be cooked. Palliative care may begin at the stage when living with the dementing illness becomes dying with it. Such care is often difficult to give the demented individual, and much research needs to be done in that area. In addition, there is an unfortunate shortage of health professionals in residential care for the aging, which must be remedied if successful palliative-care provision with appropriate family involvement is to be given.

There are strong needs for assessing the psychosocial, spiritual, and physical health needs of the primary caregiver; establishing the expectations of family for the health of the person with dementia; educating caregivers about the roles of staff in relation to patient support and end of life palliative care; encouraging ongoing communication between caregiver, family, and staff; and providing counseling and access to support groups.

Discussing another important aspect of aging, “Bioethics and End-of-Life Issues” by Gail Tulloch deals with matters of euthanasia and physician-assisted suicide. The Harvard Ad Hoc Committee (Ascension Health, n.d.) was the source of the influential brain-death criterion in the United States that became the international standard definition of death, in place of the absence of heartbeat and breathing. Permanently unconscious patients were potential sources of donor organs for other patients, but to remove the heart of a still-living patient was considered murder. Hence the Harvard definition of death was a great leap forward in terms of practice and policy.

Bills to legalize assisted suicide were introduced unsuccessfully in many states. In 1964, Oregon's Death with Dignity initiative was approved by voters, but because of an injunction by the District Court did not go into effect until 1997. Oregon is now the touchstone for the legal status of physician-induced suicide in the United States. In England, as long as the doctor's professional intention is to relieve suffering, treatment by escalating doses of morphine that leads to death is legal. The Netherlands, until joined by Belgium in 2001, was the only country that legalized euthanasia. It is interesting that while Dutch legislation was passed in 2001, it was preceded by nearly three decades of practice when doctors were not prosecuted if they followed appropriate guidelines. The Dutch definition of euthanasia is a narrow one, restricted to active voluntary euthanasia. According to Tulloch (p. 129), “Three characteristics of Dutch society concerning euthanasia are important to acknowledge: its openness, the long-term relationship people have with their GP, and the fact that nursing care is free, so there is no economic pressure to end life.” Tulloch adds that she believes the Dutch experience “is close to exemplary,” and has not polarized the country—unlike the situation in the other three countries discussed.

While there doubtlessly is much information of value to program administrators, staff, theoreticians, and caregivers of the aging in “Lessons On Aging From Three Nations, Volume II: The Art of Caring for Older Adults,” I (possibly because of where I stand in the age pyramid) found this book much less interesting than the first volume of the series, “The Art of Aging Well.” Nevertheless, Volume 2 provides much needed information on the worldwide situation of the burgeoning number of senior citizens and possible resolutions of the difficulties the circumstances entail.

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