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4.8. Aging and Nursing in Turkey: An Ethical Perspective

- Fatma ERSIN1, Ebru CEVIK1,
Sahin AKSOY2 and Nurten AKSOY2
Harran University, School of Nursing1 Faculty of Medicine2,
Saglik Yuksekokulu,  Ipekyol 63200 Sanliurfa-TURKEY
E-mail: fatmaersin@mynet.com

Introduction

Physiologically aging is an unavoidable fact. In a sense aging is a developing process starting from birth even from the intrauterine term. Aging is not an illness, but a physiological developing process going backwards. These retrogressions, if they stay in the physiological limits, can be clinically silent in the whole of the process of aging (1).

In the organism, with aging, on one side concerned with the sense organs, on the other side in the vital organs some basic differences occur (1).

The problems of aging are mainly chronic and degenerative illnesses. The probability of seeing these health problems is in a big increase with the advance of the age.

In the old age beside health problems, social problems bear big importance. The social problem is, too, in agenda, because of a person who is permanently bedfast, owing to his/her chronic illness is that beside his/her health problem, he/she has a necessity of others' care and support.

The important fact in the old age's health problems is that this point is not brought up sufficiently. Because of a complaining, an old person applies to a health institution is less, in comparison with the young people's. Some of these are common for elderly, and would not be expressed as a complaint (1). Also the physical and mental insufficiency of the elderly is a reason of applying less to the health institutions.

The geriatric problems that are seen often on the elderly are defined as the 7 "I"s of aging (2):
1-Intellectual failure
2-Immobility
3-Instability
4-Inc?ntinence
5-Insomnia
6-Latrogenic problems
7-Involvement of families

Aging causes changes in the systems of organs and tissues. To become shorter in the height, the decrease of the body water, and increase in the proportion of fat can be given as examples for the general differences of the body.

Turkey, if compared with the other countries, from the point of view of the age, it is among the countries that have a population of rather young people. However, the elderly population will come into agenda for Turkey in near future. According to the calculations, because of the various reasons, it is foreseen that the proportion of the elderly population in our general population will increase two or three times more in thirty years. Because of this the health of the elderly is getting gradually more important in our country.

Aging of the population is a new demographic problem for Turkey. In the year 1990, 65 years of age and above were equal to 4.5% of the total population; in 2025 this proportion will have increased to 9% (3).

Turkey is a society who looks after their elderly with their traditions and customs. The big majority of the elderly live with their children, the ones who live apart are in close contact. Because of this culture of harmony of family life bears big importance in the elders' problem solving. This culture includes, as if it is for that the old person can continue his/her house and family life's duty and responsibility as in the past, too, it is for all the individuals of the family to be educated, informed and to be made conscious.

In the hospitals other than general health services, the geriatric services are not enough to pay attention particularly to the elderly who need help and special care for their needs from the point of view of health (3).

Geriatric services, like the different areas of health services, have ethical problem's peculiar to them. The major ones are;
1-Informed consent
2-Abusing the elderly
3-Unequal treatment according to the age
4-Long lasting care
5-Health service to the elderly

In the contemporary medical science one of the important principles is the patients' participation to the process of decision making. For this, three basic components are needed. These are:
- Competency
- Willingness
- To be informed about the illnesses.

Competency:
An ethical decision needs the patient's cooperation. For patient's decision making competency he needs mental power, communication and understanding ability, has some values and aims, and to think about a decision, and to have a mental power based on reasoning. Age cannot be a sufficient base itself to deny a persons right to decide for himself, provided that he has mental competency. Especially the mental competency of the patient who refuses the treatment must be assessed. And the nurse has to assess the patient's decision of mental power and has to give a care in this direction.

Willingness:
Willingness is that the patient makes his choice willingly and without being directed. Elderly individuals are in the tendency of thrusting and being dependent to the people whom taking care of them. In this situation not only the health personnel (doctor, nurse etc.) but also the elderly have to know the restrictions formed by the treatments and the standards of judgement of each other. Only by this way they can they help each other.

To be informed about the illnesses:
Informing the patient about his illness procures to have an approval from the patient, for the clarification of this approval, and for deciding himself. Because of this, the patient has a right to obtain all the information about the decisions that concerns him. The nurse is the closest person to the patient in the health care team. For this, the nurse has to watch over the willing to know of the patients concerning the information about his illness and guide the health care team this direction.
The more the elderly individuals in the society increase, the more the spending, which has to be done for providing medical and social support increases.

Abusing the elderly:
If there is not a primary connection between the helper and the getting help of the old individuals, it can reflect the stress, which is created by the social and economic coherence, the elderly individuals have to support their life with. Abusing can be not only in the nursing homes, but also at home. In Turkey, some standards of judgement, like taking care of elderly is a shame, affects the quality of care. The manner of conduct and behaviours, which are the reasons for abusing, can be originated from the family individuals, the person who takes the responsibility. These abuses are not much evident, they reflect the personal values. In this way, the dependence process for the elderly is concerned with the conduct they meet, and their physical and mental health is influenced. And thus, at first not the elderly, but the other individuals of the family who care and look after them have to be educated.

In the national health services the families' and the aged persons' responsibility on their shoulders have to be decreased by increasing the care services at home with the visits made by nurses to the elderly, by evaluating the elderly in the family environment and by the care given to them. In this way, it will be achieved for the elderly to gain their independence, so the abuse will be stopped. All the gerontologists think that elderly abuse is a problem. Some of them believe that the society will achieve much more benefits by instead of developing a different answer system for the elderly population's very minor section, to protect the elderly individuals income whose attentions are not strong, and by the focusing the medical care and social services (3).

Age Discrimination:
Age discrimination, "ageism", because of the individuals' chronologic age, according to the other individuals can be defined as to act more badly. Age discrimination may include the children and the elderly; but in practice the elderly are more exposed to discrimination (3).

In the advanced age, at the top of the subjects, which concern the discrimination, is the resource of the society, especially health care resources. In a research we have conducted before 45% of the Turkish society told that age should play role in decision making at the end of life. This result was a bit surprising for us. We were expecting far less people would say this. We assume that the present economical crisis in the country, and the lack of facilities with high unemployment rate lead people to answer like this. So we assume it was a wrong time to ask this question (6).

All of us who want to continue life have one thing, we gave the same value of shape, but which has different quality for each of us, which is for some much more full of prizes and which none of us know the real shapes of it. This thing is of course "the rest of our life". Whether in the age of seventeen or seventy, whether healthy or in a lethal or hopeless illness, each of us have a life to continue. Each of us who wish to live the rest of our lives does not deserve to be shortened our life. And if our willing is hindered intentionally or if we die prematurely it is unjust for us. Only because of the difference of the birth date, of course it has to be seen injustice that some deprived of something that everybody gives a big value (5).

The distribution of the health sources has to be distributed according to the equality principle. As Harris mentioned the health services (preventive or treating) exists to protect the right to life. Here as these services are given, the discrimination according to the age is the biggest injustice to the elderly individuals (5).

Although, the health sources distribution in a general meaning include political decisions, all of the health workers have to product new projects and have to work for equal distribution.

In particular, in the preventive and treating services they are responsible with the active using of limited sources. As this responsibility is brought in duty, the quality, which is given to the old individuals, will be increased. Besides "patient rights defending" is one of the duties of the nurses. When the old individuals meet with injustice due to their ages, to defend their rights and to give education according to this subject to the elderly, and to guide them is a duty of the nurse.

Care is basis necessities for human .To do the works that other individuals cannot do, is a state that needs time and resource. Medical developments have increased the number of individuals in any age who need care. And the longer life expectancy has been a reason for increasing the necessity of the people who care, compare to the previous years.

In the long term care giving institutions, respect to the confidentiality, full participation to the care plan, the individuals giving a decision in the subject of their treatment and other rights have to be provided to all individuals who stay in these institutions.

The attributes of the old age illnesses influence the ethical elements of the health services given to these individuals. Old people are exposed to more distress due to the illnesses compare to the young. In general, the elderly have different chronic medical conditions, and including to the admittance to the hospital, they have more frequent need for health service.

In such situation the nurse who is the centre of the care has the most active role in increasing the elders' life quality. There are some points to be taken into importance while giving old individuals care. The nurse must act professionally from informing the patient about the procedure, to the terminal term of the elderly who are prepared to death. Because elderly are individuals who are inclined to be dependent. The nurse, whether in treatment or preventive services, has to plan the services she is going to give to the aged individual and his family. This provides the sensations of confidence between the old individual and the nurse, and makes the application functions easier. The nurse has to make an explanation to the old person before every procedure. This information has to be suitable to the old individuals' cultural, physical and personal situation.

The nurses should take part in the establishment of nursing homes, clubs and associations for the elderly to improve their social sides. The nurses should not be in paternalistic attitude against patients. They have to give a service that makes the old person self-confident, is rather responsible of his own care, and is independent.

Conclusions

As a conclusion, this study aimed to demonstrate the ethical problems in health services that are given to aging people, and to bring up some suggestions from nursing point of view.

While some solutions for the problems of aging people are searched all around the world, we wanted to show the deficiencies in this subject in Turkey. There is a Turkish saying; "Two days in the bed, third day in the earth" that summarizes the lack of confidence of the elderly to the health services, family members and government, and the hopelessness they have lived. We hope that in gerontology develops as a science in Turkey, so the worries the elderly turn to hopes.

References

1) Bertan, M., Guler, C.(1997): Problems of Aging, National Health Basis Knowledge Book, Gunes Bookstore:366-367.
2) Arslan, S., Kutsal, Y.G. (2002): "Geriatrics and Ethics", in An Ethical Look to Life, Ankara Medical Association Publications:113.
3) Buken, N. (2002): 'Aged Population From Ethical Perspective", in An Ethical Look to Life, Ankara Medical Association Publications:133-156.
4) Rudolf, M.S. (2001): Is Elderly an Ethical Problem in Health and Illness?, Nobel Medical Bookstores:305.
5) Harris, J. (1985) The Value of Life, Routledge, London:132-133.
6) Aksoy, S. 'End of Life Decision Making in Turkey' in Ed. Blank R. H. End of Life Decision Making, MIT Press, (forthcoming)

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