End-of-Life Decisions and Late Adulthood

October 10, 2007 at 10:37 am  •  Posted in Advance Care Planning by  •  0 Comments

By Kathy Tedesco, BSW

Religious Beliefs and Advance Directives
Changes as We Age
Erickson’s Theory of Psychosocial Development and Late Adulthood Decision Making
How Social Workers Help



Medical evidence has shown us that that people are living longer with chronic illnesses during the 21st century than they did in the recent past. Advances in medical technology have allowed health care providers to sustain a person’s life artificially. Most of us have heard of news stories of people who have remained in a coma for many years kept alive through medical intervention.

Historically, the act of dying is seen as solely a medical event. However, there is now a movement to incorporate the psychosocial, spiritual, and personal aspects of dying: advance directive planning.
An advance directive is a legal document that puts a person’s wishes about medical treatments in writing. Advance directives generally fall into three categories: living will, power of attorney and health care proxy.

These documents are directions for a person’s care that they can have in place in advance of perhaps becoming incapacitated by illness or injury when they can’t make their wishes know to their physician and family.  Although any adult create an advance directive for themselves, most adults  who have these documents are age 65 and older.

Advance directives also allow individuals to make important medical decisions, for instance artificial nutrition and hydration, etc. According to the Patient Self-Determination Act, passed in December 1991,  health care providers receiving Medicare and Medicaid funds must tell patients of their right to make these decisions – in advance – if they become medically ill and/or unable to speak for themselves.

Religious Beliefs and Advance Directives

Studies have shown  that religion is a major influence in an individual’s view of life, death and the healthcare system. One study focused on the elderly and how the primary factor was based on their own life experiences which were influenced by their spiritual beliefs.

End-of-life decisions can affect a person’s spirituality since their quality of life may be an important factor in their spiritual well-being. Other factors that may determine how a person feels about their end of life include the impact of where they have grown up and live, personal factors, their education, their knowledge of advance directives, their fear of death, and the amount of social support they have. Studies demonstrate that people become more religious as they age, and some people go back to their religion when faced with death. It is felt that religion promotes emotional well being later in life.

End-of-life decisions can also affect a person’s physical, emotional, and social development. Elders have had to cope with losses throughout life. Many  concerns that the elderly have tend to be “psychological in nature” such as a fear of requiring 24-hour care or institutionalization due to failing health. These psychological affects can lead to depression.

Changes As We Age

During later life changes occur such as becoming frail and medically unstable. This is when advance planning decisions can be made to determine what life sustaining measures will or will not be taken to sustain life.

Social changes affect a person’s decision. If they move, for example, to be closer to family, they will need to make new friends in the new environment, to cope with the loss of old friends, and to cope with the changing roles within the family dynamics as one becomes older.

Family members most likely will be the decision makers for the patient. It is important for families to inform healthcare providers of the patient’s beliefs and values, as well as the family needs, expectations and concerns. The older adults have to deal with being a lower status in society and possible threat of ageism, as well as retirement and lower income.

Erickson’s Theory of Psychosocial Development and Late Adulthood Decision Making

The renowned psychiatrist Erik Erikson based his concept of a complete life cycle on Freud’s theory. Erikson took a “psychosocial approach to human development,” paying specific attention to the individual and their environment, as well as human services available. The emphasis was on the “person in (the) environment”.

Erikson’s view of life was explained through eight different life stages. A person faces a crisis and progresses through to the next stage whether or not they resolved that crisis. Erikson reported that the resolution of each life crisis is an ideal, but that does not mean it is always a reality. He defined the late adulthood stage as age 65 until death. According to Erickson, a persons’ positive outlook on wisdom is important and the conflict within a person is between (ego) integrity and despair. This is when a person tends to reflect on and accept one’s own life.

Some people are able think of aging as a natural progression in their life and accept death as the ‘completion of life.’ To the ability that a person can resolve a crisis in the earlier stages is an indication of their ability to resolve their crises within later stages.

Others may not be able to cope with the end of their life successfully and can become very upset. They can experience a lot of regrets and suffer with  deep despair over their life experiences and events they perceive as failures. They may struggle with the thought of the end of their life, and what their life means. On the other hand, some people might feel that they were an intricate part of society and are able to leave this world with the belief that their point of view was always the correct one.

Near the end of life, a person can be mentally and physically incapacitated. In order to make sure they have a “voice” during this time of important decisions, a policy and law was developed to educate and encourage people to document their wishes prior to a devastating illness. It is an individual’s right to make end of life decisions and to determine what medical treatment they want or do not want.

How Social Workers Help

Social workers carry a responsibility to educate and inform patients about advance directives in order to explain their meaning. It is vital for social workers to enable patients to make informed decisions and therefore good communication skills are vital. Social workers need to be sensitive to a person’s vulnerability that might be a result of poverty, bias, oppression or prejudice. We as social workers need to identify the issue at hand and work toward alleviating burdens when possible. Social workers are required to ensure that policies and practices reflect true choice and do not discriminate against traditionally oppressed groups such as people of color, women, disabled, gays and lesbians. Social workers are ethically bound to challenge injustices, and respect the dignity and value of the person.

The NASW code of Ethics, 2000, indicates social workers have a responsibility to assist clients in asserting their rights to self determination and informed consent. NASW’s position suggests that for the terminally ill population, the ethical issue of the right to self determination outweighs the social worker responsibility to avoid doing harm. In June 2003, after social workers continued studying of end of life decision, NASW implemented the “End of Life Practice” policy. It states the social worker has the responsibility to assist clients and families in end of life decisions, and if for personal reasons the social worker is unable to, the social worker has the responsibility to refer the client and family to another competent professional.

Studies demonstrate that poor and underinsured persons often receive substandard healthcare which may result in a higher mortality rate. Poverty is different for each race and ethnic group; minorities are more likely to be disproportionately harmed by this issue. If the person is publicly funded, the medical doctor is more likely to write a do-not-resuscitate order.

Due to advances in healthcare, medical treatment options have become complicated. Some decisions made which intended to alleviate pain may hasten death. For others, actions being taken can lead directly to their death, such as the removal of artificial means (feeding tubes or respirator).

On a macro level, as healthcare, health policy and social contexts continue to progress, social workers need to continue to educate and inform people of end-of-life policies and practices. On a micro level, social workers need to continue to encourage people to make informed decisions and understand what their end of life care entails in all aspects: through the total body of health and illnesses by including the biopsychosocial and cultural aspects. As social workers continue to serve devalued groups (elderly, poor, disabled), they need to continue to advocate for more equitable social policies regarding end of life decisions and for better access to resources.

We, as a society, have to help preserve the dignity and respect that our older generations once had and deserve. They preserve our history. They are our future. This generation possesses a knowledge and wisdom that the younger generation can benefit from by learning.


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