Advances in medicine have prolonged the life of many people. As a result, aging of the population results in an increasing number of people living with chronic disease. Those living in community are seems to be independent, but in most of the time are in need of much support in their daily living activities. Furthermore, chronic diseases may not kill but they consume a lot of health care resources and threaten the quality of life of the sufferers. In these circumstances, arises the big question- which of two would be the appropriate team to be treated until the death- the nursing home personnel or the family at home. Sometimes, when the situation becomes too difficult, older adults and their families have to decide where continue to live. Their choices are limited by factors such as kind and stage of the illness, financial, physical and psychological resources, and personal preferences. Making a decision that is best for your parent—and making that decision with your parent—can be difficult. The decision about whether your parents should move or stay and receive help from a family outsider for a few hours a day or permanently for 24 hours, – is often tricky and emotional. Each family will have its own reasons for wanting or not wanting to take any such a step. One family may decide a move is right because the parents no longer need so much space or cannot manage the home. For another family the need for hands-on care or a long-term care facility motivates a challenge. In some cases, a move frees up cash so that the parent can afford a more suitable facility to move in. In the case of children living fare a way, the notion of moving can seem like a solution to the problem of not being close enough to help. For some, moving a sick or aging parent to their own home or community can be a viable alternative. In some cases, an adult child moves back to the parent’s home to become the primary caregiver. All of those staying in community and not entrancing in a nursing home options demand from the patient's family sometimes sophisticated realignment. Therefore, it seems to be understood by the society, that seriously ill elderly might be institutionalized in some "places with good treatment", as hospitals, nursing homes or hospice facilities. In contrary on this common opinion, people who are chronically ill choose to remain at home or enter a home-like alternative care setting. The role of geriatric doctor is to support the position of those people whenever trying to satisfy the desire to stay at home and prefer their maybe- but not necessary- less professional but much more worm and loving family at home or intrance into an institution with qualified personnel and all available necessary equipment.
Those options will be discussed with the patient and his family by six features: quality of life, convenience for the elderly, effectiveness of care, community resources and patient rights, psychological aspects and patient’s and his family personal involvement in treatment and decision making levels. Geriatric Medicine follows the Greek word geron, "an old man," and iatreia, "the treatment of disease." Geriatric medicine involves the recognition of differences in presentation of disease and the importance of maintaining functional independence in elderly patients. Geriatrics is a primary care discipline oriented toward preventive, routine, acute, and chronic medical care of elderly patients. Important procedural skills include cognitive assessment, functional assessment, gait assessment, home safety assessment, motor vehicle driving assessment, and needs assessment on hospital discharge, including rehabilitation. The field of geriatrics began measuring and researching outcomes using such variables as an individual’s ability to function and their quality of life. The geriatric population often has multiple chronic conditions and functional limitations. Single physiological measures are not adequate to meet the needs of this population. As it was mentioned before, the ultimate goal of modern health care for patients with chronic disease is not so to delay death, than to promote health and quality of life. The key objectives of their treatment are to obtain high-quality palliative care, control pain and preserve the highest possible quality of life for as long as life remains. Ensuring optimal care depends on the nature of the specific disease process that is leading toward death. Of course, it seems to be easier to provide better care in hospitalization settings, but is this kind of care preferred by our patient, do he see quality of care adequate to quality of his life, or even health? In many cases, there isn’t any correlation between those two definitions. We can easily meet a patient, who would prefer even shorten his life instead of suffer of being far away from his family and his home.
For elderly people, the decision to be treated by home care team is often linked to more general issues regarding basic living arrangements, finances, and aging. When not finding those who can support them in their community, they might have not a choice than entrance to a nursing home, where those issues are already resolved. On the other hand, many eldercare resources exist to help family provide qualitative care for the total person at home. If staying home, those community-based services become the essential need of citizen's majority. The focus for them is to shift from the place of care, as nursing homes and hospitals to the type of care- home based care, mentioning the older adult's convenience, independence, dignity and quality of life. Professional care managers are usually licensed nursing or social work professionals who specialize in elderly care, or as we call it- geriatrics. Therefore, for better rout and focus on real needs and treatment options offered by the family caregiver in their Health Services Organization (Kupat holim), and organizing a continuouse care coordination involving community resources, making an appointment with a gerontologist- a physician specialist in geriatrics, and having a discussion during this consultation should be a necessarily stage in the decision making process in issues connected to eldrly health. Professional in geriatrics is the best adress to "tailor" majority of treatments as palliative care and pain management to each person due best evaluation and assess of their needs knowledge and common practices.
In nursing home, the personnel take care of all relevant to the patient things, involving him or his family in fundamental, general but not particular issues. The claim is "to liberate the family from concerns about their loved one". As it was mentioned before, the goal of based on home resources care in community is to facilitate the patient’s transition from sub-acute care to self-care and to promote the maximally patient’s independence in care. Similarly to nursing homes and hospitals, those are promoted by good care, throws identifying the early signs and symptoms of deviations from the normal- the area of geriatric expertice. Yet, in contrary to nursing homes, in combination with those more technical interventions performed by the Health Services Organization’s home care professional team, self-care assistance in mobility and psychosocial issues can be considered the one of the most frequently performed core interventions in geriatric field, all of those- by proper education and cooperation of all members of care team, including family physician and family caregivers. The professional can also be helpful in leading family discussions about sensitive subjects as death and dying process. Often families feel it is "too soon" to begin professional geriatric care and wait until death is very near. Bringing home gerontoligist in at the last minute limits their effectiveness. Therefore it seems to be difficult treat an elderly at home. In this circumstances in most cases there would be no another option than hospitalization. In contrary, a better approach would be to begin some level of professional care before a crisis exists, beginning by arranging introductory home visits well in advance of need and obtain counseling from professionals that can provide helpful suggestions on care arrangements..
Chronic disease can also affect an individual's psychological status. Physical illness, an awareness of one's own mortality and a negative impact on social functions contribute to depression, introspection, sleep disturbance and anxiety. Social activities are progressively impaired with increasing severity of the chronic disease. Personal relationships, eating, sexual activity and ability to work are all curtailed whilst paralleled by an increasing dependence on others. All of those might bring to infringing of individual's autonomy, complicated by recurrent and finally permanent hospitalization. Additionally, whole the process of decision making and involvement in care may intensify feelings of grief and bereavement, both in the person who is detoriating and in his relatives. Conversely to connections detachment usually related to institutionalization, the fact of staying at home can break through determination from the outside and inside of the family world by reinforcement and rehabilitation of old relationships, definitely improving health status of the elderly. Also, many support groups are available to help through this end of life process, including groups for bereaved families.
Working collaboratively with the family in residential aged care to provide care is consistent with geriatric philosophy. The quality of the experience, however, is frequently fraught with problems for both the family and staff involved. Equally, many attitudes which cast the family into an adversarial and competitive role were noted, and many staff members outlined practices which were indicative of a need to control the family. Similarly, rhetoric of family partnerships is prevalent in most of nursing homes. The activities of staff in these homes are still primarily geared towards provision of physical care, and families’ needs become secondary to getting the work done. A different model of practice, that sees working collaboratively with families as a legitimate and necessary part of the staff role, is functioning in home care. Here we have a big difference between the concepts of "team" in both systems- in community the patient himself, as well as his family, are active members of treatment team. The key word to this kind of treatment is "empowerment", which has become a popular, widely used term today, not just in medicine. By this word we describe the concept of coping and well-being in patients through reflection and dialogue, revealing their own resources and limitations in times with sickness and reduced functionality to promote the patient's choice to act and cope. Using education program by gerontologists means to "be educated through the dialogue with the patient, and to look for the patient's own meaning of being frail and elderly. The coping and self-care solutions for the patient may then even be different from the preferences of other professionals, and this does not mean that the empowerment strategy is a failure or that the patient then has to continue without the assistance from them. Within an empowerment strategy, the important thing is that both the patient and the professional together critically reflect on the meanings of the sickness so that the patient can be able to make his own conscious choices. This decision may be closely connected with a desire to achieve death with dignity.
In conclusion, aging of population brings with it a new problem, as coping more with life quality issues than with death. The situation acquires creating new, more cost-effective and improved interventions emerging effect of patient's health outcomes to shift the way health care providing is received from hospital-like to home care. Information gleaned from health professionals might to be used in a shared decision-making model to help patients make more informed choices about their health care. Health professionals as gerontologist might provide a service to help patients make personal health care decisions. Healthcare providers might work with a patient to ensure that he or she understands the various implications of the choices facing him or her, including possible health and well-being outcomes and incorporate interviews with patients who have undergone treatments and have experienced both positive and negative outcomes. The gerontologist role is to examine thoroughly each option so that the patient, along with his family and physician, can decide which option best suits him or her.
Staying home elderly can be effectively treated there, supported by home care specialists, which might help the family dealing with are actual care, effective collaboration between all care providers, community resources inaction, information providing and psychological support, patient and family empowering, and educational process. It is essential that the conducted patient's care plan will be appropriate, effective, and meaningful for each individual to improve the quality of his life in as many as possible aspects.
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