Transcript No Slide Title

FACET - European Journal of Cancer Care
March 2003
Older People, Care, and Cancer: A Critical
Perspective
BAILEY, C.1 & CORNER, J.
Slide One
Older people and cancer: the
demographic picture
• In Western societies the number of
older people is growing, and older age
groups represent an increasing
proportion of the population.
• Cancer disproportionately affects
those aged 65 and over, so the
number of older people diagnosed
with cancer is expected to rise in the
future.
• Older people have been described as
bearing the brunt of the cancer
burden.
Slide Two
Old age and science
• The characteristics of old age may not
seem to be in question, because we
often think of them as having been
‘scientific’ discoveries.
• For the purposes of research and
academic study in health care, terms
like ‘old’ and ‘the elderly’ are often
given objective reference points.
Notes
Demographic and epidemiological arguments
pointing out the potential consequences of a rise in
the number and proportion of older people in our
society have been well publicised. However, some
writers have questioned the way in which older
people have been represented.
Victor (1994) argues that the increase in the
number of older people in the UK is relatively
modest, and that the numerical size of the increase
‘does not seem to merit the panic aroused in those
responsible for health and social policies’ (p.90).
Perhaps our beliefs about older people have given
us a distorted view of the future. One article, for
example, asks whether the elderly are ‘an
oncologic time bomb’ (Anon, 1991).
How many of our views involve such damaging
classifications? Do we think of increasing age as a
source of fundamental ‘difference’ that sets us apart
from our fellow citizens? What might the
consequences be for caring practice?
Notes
It is common to see ‘elderly’ defined as 65 years and
older, and to find categories like ‘young-old’ (65-74
years), ‘middle-old’ (75-84 years), and ‘old-old’ (85
years and over).
However, the chronological age used to define ‘old
age’ is largely arbitrary and varies culturally and
historically (Victor, 1999).
Definitions and categories of old age could be
thought of as part of a specifically statistical or
demographic way of looking at things. It is
sometimes argued that this viewpoint is
‘constructed’ or ‘ideological’. It serves to make a
scientific or objective point of view possible, but may
obscure experienced – or personal and individual –
aspects of ageing. Caring for a person involves
subjective knowledge of them, as well as knowledge
of them as an instance of objective scientific fact.
Estes & Binney (1989) argue that the biomedical
model ‘equates the elderly person with his/her
disease category’ and thus considers ‘only part of
what makes him/her human’ (p.588).
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March 2003
Older People, Care, and Cancer: A Critical
Perspective (continued)
Slide Three
Age and functional status
• Older age is often presented in the
health care literature as part of a
process of deterioration and
decline.
• Older people are statistically more
likely to experience functional
disability.
• This may make it easier to justify
the association of an older person
with his or her ‘disease category’.
Slide Four
An example from research
• Koch & Webb’s (1996) study of
older people in hospital describes
care that resembles a ‘routine’ or
‘conveyor belt’ approach.
• Individual requirements were not
acknowledged.
• Patients disliked being segregated
or labelled as different on the basis
of their age.
Notes
There is a risk of making primary sense of older
age as a period of increasing functional impairment,
physical limitation, and psychiatric disorder. Older
people may be thought of as ‘adding to the burden’
of health services that are already stretched to
their limits.
Older people, as a group, are sometimes
interpreted as a ‘problem’ with severe
consequences for the economy and health and
social care care systems.
Once defined as a problem, some people argue, it
is easier for social groups to be thought of as the
responsibility of ‘experts’ – academics and
professionals – whose task it is to develop policy
and strategy. The focus shifts from the individual
to the ‘expert’. One view of health care is that the
power to define need and establish expectations is
largely in the hands of professionals and academics
whose knowledge gives them expert status.
‘Problematised’ groups are vulnerable, and may be
marginalised in terms of their contribution to our
understanding of well-being.
Notes
Baker (1983) argues that the ‘routine geriatric
style’ of care is based on a notion of the older
person as a ‘stigmatised individual’ (pp.110-111),
and that it puts orderliness above individual need.
Baker refers us to Goffman (1968), who explains
that someone who is ‘stigmatised’ is ‘reduced in
our minds from a whole and usual person to a
tainted or discounted one’ (p.12).
Koch & Webb (1996) associate routine care with a
single set of norms that are determined by the
requirements of an institutional schedule. Needs
are defined not by referring to the individual, but
by referring to a series of standard values and
associated nursing practices that include hygiene,
pressure area care, medication and food.
They quote from Ada, who has metastatic cancer:
“I am sitting out of bed but I don’t want to be here.
They just sit everyone out of bed … They are all
resolved to put everyone in their chairs. That is
the important thing” (p.955).
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March 2003
Older People, Care, and Cancer: A Critical
Perspective (continued)
Slide Five
The ‘biomedical construction’
of old age
• The ‘biomedical’ view has been
associated with the idea of the
person as a machine or container
for the mind.
• As a machine, the body can be
‘repaired’, but can also ‘wear out’
over time.
• This view tends to confirm the idea
of ageing as a time of deterioration
and decay.
Is ‘old age’ just a way of thinking?
Slide Six
• Bytheway (1995) has argued that old
age and ageism are no more than ways
of thinking.
• He believes that we cannot ‘rethink’
ageism without questioning the
presumption that ‘old age’ exists.
• ‘The elderly’ or ‘the old’ could be
thought of as socially constructed
categories that make it legitimate to
separate and manage people on the
basis of their chronological age.
Notes
Interpretations of the body as a machine or
mechanism that is separate from the mind (or ‘self’)
may have important consequences for caring
practice, and for the care of older people in
particular.
If we view our bodies as machine - or object -like,
it seems normal to allow specialists in the ‘repair’
of bodies a wide degree of control over them. ‘As
a machine’, Koch & Webb say, ‘the body can be
entered, studied and tampered with in order to be
repaired’ (p.957). Attention to the objective body
means that the ‘patient as subject fades into the
background’, and the individual is left with a
diminished role in the process of setting the agenda
for care and well-being.
The ageing machine/body is subject to increasing
amounts of wear and tear, so that it becomes, in
effect, a ‘failing mechanism’. This, Koch & Webb
believe, has contributed in health care to the
negative stereotyping of old age as a time of decay
and deterioration (p.958).
Notes
According to Bytheway (1995), ageism is an
‘ideology’, a shared system of ideas or beliefs that
‘justifies the interests of dominant groups’
(GIddens, 1989).
Bytheway explains that in health care, doctors may,
having taken account of symptoms and clinical
evidence, aim ‘more for amelioration than cure’ in
their treatment of older people (pp.127-8). If this
practice is based on clinical judgement and takes
full account of the benefits and risks of the
alternatives, it reflects ‘a recognition of the physical
realities of age rather than the power of ageism’
(p.128). If, however, ‘treatments are systematically
barred to people over a certain age because of a
presumption that there will be no benefit, or
because younger people are systematically given
priority, or because limited success could lead to a
continuing burden, then this is institutionalised
ageism’ (p.128).
To ‘take on’ ageism, we must, in effect, abolish the
idea that age is a legitimate basis for distance or
separation between individuals.
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FACET - European Journal of Cancer Care
March 2003
Older People, Care, and Cancer: A Critical
Perspective (continued)
Slide Seven
Images of older people
• Johnson & Bytheway (1997)
reviewed photographic images of
care work with older people from a
popular magazine.
• The most common image was the
‘caring about’ photograph.
• This image suggests that health care
aspires to ‘care about’ as well as to
‘care for’ older people.
Slide Eight
• The images also suggest a view of
older people as ‘passive, controlled,
and dependent’.
Notes
In the ‘caring about’ photographs, Johnson &
Bytheway found that both the younger carer and
the older ‘cared about’ person were often women
(79% and 87% respectively).
In a majority of the photographs, the younger
person is leaning towards the older person (55%)
or taking up more space (57%). In some
photographs, the younger person is making a
conscious effort to face the older person on the
same level. In others, the younger person is more
prominent, or the older person appears to be on
show, or an exhibit, to be inspected by the younger
person and the reader (Johnson & Bytheway, 1997,
pp.136-7).
This, Johnson & Bytheway believe, shows that the
images reflect the aspirations of health care to
‘care about’ as well as ‘care for’ older people, as
well as a view of older people as ‘passive,
controlled, and dependent’ (pp.137-8). Images like
these, they suggest, contrast sharply with more
realistic and challenging images that ‘ignore the
association between age, care, and dependence’
(p.141).
Non-persons and social death
Notes
• The very old and the sick have been
identified as categories of ‘nonperson’.
It is Goffman (1959) who identifies the the old and
the sick as kinds of ‘non-person’, by which he
means people who are treated as if they were not
there.
• A ‘non-person’ is someone who is
treated as if they were not there.
• Hospital patients can become nonpersons before their actual death, if
other people’s behaviour towards
them reflects a recognition they they
are dying in a clinical sense.
• Being treated as a non-person in this
way has been likened to a kind of
‘social death’.
Mulkay & Ernst (1991) say that the ‘sequence of
physical decline that we call “dying” is accompanied
by a sequence of social decline … In many cases,
although the patients’ basic physiological
requirements continue to be met … he or she
ceases to exist … as an active, individual agent
some time before biological termination takes
place’ (p.174).
Mulkay & Ernst point out that older people ‘are
likely to find themselves … subject to a general
physical aversion which is akin … to the revulsion
caused by dead bodies’ (p.181). They point to
research by Sudnow (1967) in which hospital staff
are seen to ‘deal with all their elderly patients in a
special way which follows from the latter’s
proximity, as elderly persons, to biological death’ (
p.181). In other words, elderly people in hospital
are already located in a ‘social death sequence’.
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March 2003
Older People, Care, and Cancer: A Critical
Perspective (continued)
Slide Nine
Older people and acute illness
• Latimer (1997) describes the case of
91-year-old Jessie, who has had a
stroke, and argues that she is classed
by hospital staff as an ‘old person’ not
an ‘acutely ill’ person.
• Her problems are interpreted as the
natural consequences of getting older.
• She is therefore not the responsibility
of medical staff, and falls outside the
legitimate scope of health care.
Notes
Latimer’s ethnographic research was carried out
on an acute medical unit of a large British hospital.
Her account of Jessie is based on conversations
with a ward sister.
She argues that the category ‘older people’ is
absurd but inescapable. We are all part of the
process of creating this distinction, because we all
fear increasing age. At the same time we are all
always already ‘becoming older’.
The ward sister, Latimer says, has ‘refigured’ or
‘redefined’ Jessie by removing her from the
category of ‘acutely ill’ person, and placing her in
the category of ‘old person’. Because ill health in
old age is seen as biologically inevitable, it is part of
the natural order of things. Jessie is ‘out of place’
in the medical ward because as an old person, she
is subject to progressive decline until death, and is
unlikely ever to fulfil medical ambitions of an
‘heroic’ recovery.
The primary association of ageing with physical
decline means that older people fit uneasily into the
domain of professional care.
Slide Ten
Older people and cancer
treatment
• Questions have been raised about
certain aspects of the treatment of
older people with cancer.
• Some research suggests that
differences in treatment received for
cancer may be age-related.
• Is there a rational explanation for the
differences in treatment received by
older people with cancer, or are the
differences due to ‘ageism’?
Notes
In 1991, Fentiman et al published a paper called
Cancer in the Elderly: Why So Badly Treated?
Even ten years later, the question posed by this
paper sets us an important challenge: to ensure that
older people are given the same opportunities as
their younger counterparts when they have cancer.
Some commentators believe that older people with
cancer can be subject to age bias: ‘age-related
differences in … post-diagnostic treatment suggest
a deep … social “ageism” influencing who receives
aggressive treatment’ (Mor et al, 1985).
Others believe there are good reasons for agerelated differences in treatment. Guadagnoli et al
(1997) conclude that in early stage breast cancer,
for example, the decline with age in the frequency
of adjuvant chemotherapy is consistent with the
diminished efficacy of the treatment in older
patients. What is important is that we all take the
question of age-related differences in treatment
seriously.
slides available at: www.blackwellpublishing.com/journals/ecc
FACET - European Journal of Cancer Care
March 2003
Older People, Care, and Cancer: A Critical
Perspective (continued)
Slide Eleven
Chemotherapy
• Some research has shown that older
people with cancer do not receive
adjuvant chemotherapy as often as
younger people.
• Fear of increased toxicity may
discourage doctors from offering
this kind of treatment to older
people.
Slide Twelve
• Some studies suggest that older
people, in general, do not tolerate
chemotherapy less well than
younger people.
Notes
Newcomb & Carbone (1993) found that women
aged >65 received radiotherapy and adjuvant
chemotherapy for breast cancer less often than
women aged <65, and that chemotherapy for
colorectal cancer was less common in the older
age group. In their study, De Rijke et al (1996)
found that stage of disease was unknown in a larger
proportion of older patients, that older patients
were more likely not to be treated, and that older
patients were more likely to receive single modality
treatment.
Popescu et al (1999), who studied palliative and
adjuvant chemotherapy for colorectal cancer in
patients aged >70 years, concluded that
chemotherapy is well tolerated by older patients,
that the palliative benefits are similar for fit older
and younger patients, and that adjuvant
chemotherapy should be offered using the same
criteria that are applied to younger patients.
Schrag et al (2001) ask why elderly patients do not
receive potentially curative adjuvant chemotherapy,
and raise the possibility of nonmedical barriers to
care.
Final thoughts
Notes
• The extent to which nonmedical
barriers to care affect older people
with cancer should be carefully
considered.
There is an increased likelihood, with age, of
functional disability (Silliman et al, 1993), and this
might affect patients’ decisions not to proceed with
adjuvant treatment, for example. The role of
functional status and comorbidity in decisions
about adjuvant treatment is not fully understood,
however, and we need to know more about
exactly how important these factors are when such
treatment is either not offered or not pursued.
• We do not yet fully understand the
influence of age itself, social resources,
cultural barriers, professional attitudes,
or patient preferences on treatment
decisions in older people with cancer.
• Could better patient outcomes be
achieved if we could overcome some
of these ‘barriers’?
The question of whether patients do not proceed
with treatment because they judge themselves illsuited to do so, or whether they are in effect
prevented from doing so because of some
(potentially) remediable lack of necessary support,
is a particularly crucial one.
We need to ask ourselves whether, if
comprehensive support were to be more readily
available, more older people would choose to
receive extended treatments for their cancer. We
might also ask ourselves what, in these
circumstances, the effect on patient outcomes
might be.
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FACET - European Journal of Cancer Care
March 2003
Older People, Care, and Cancer: A Critical
Perspective (continued)
References
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FACET - European Journal of Cancer Care
March 2003
Older People, Care, and Cancer: A Critical
Perspective (continued)
References (cont.)
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Popescu, R.A., Norman, A., Ross, P.J., Parikh, B. & Cunningham, D. (1999) Adjuvant or palliative
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Footnotes
1Chris
Bailey is Research Advisor for the Wessex Primary Care Research Network, Primary Medical
Care, University of Southampton, and a lecturer in the School of Nursing and Midwifery, also at the
University of Southampton.
Jessica Corner is Professor of Cancer and Palliative Care, School of Nursing and Midwifery, University of
Southampton.
Correspondence address: [email protected]
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