FEBRUARY 5, 1996 VOLUME 3, NUMBER 32
The “Aging of America” is a familiar theme. Almost everyone knows that our population is growing collectively older, and that seniors are the fastest growing segment of our society.
Aging Americans are not monolithic, however. A number of demographic trends appear among the increasing numbers of the elderly.
The dimensions of the change in society are astonishing. Although only one in twenty-five Americans was over the age of 65 at the turn of the last century, one in eight are at least that old today. Shortly after the next turn of the century, “Baby Boomers” will begin to join the ranks of the elderly, and one in five Americans will be elderly by the time the last Boomers turn 65 in the year 2030.
Older Americans will be increasingly diverse in coming decades. Although about 10% of seniors are members of at least one minority group today, that percentage will double in 50 years. Hispanics, for example, will increase from 4% of the elderly population to 16%. But the biggest increases in the elderly population will continue to be among the oldest Americans.
Since 1960, the country’s population has increased by about 45%. The number of over-65 Americans doubled in the same period. But the over-85 crowd has almost quadrupled in the same period. And those trends will continue; by 2050, the number of over-85 Americans will increase by over 500%, and the ratio of over-85s to over-65s (currently about 9%) will triple.
Women live longer than men and so make up a majority of the elderly. In the first five years after age 65, women outnumber men 6 to 5; among 85-year-olds the ratio is 5 to 2. And women are more likely than men to require assistance with activities of daily living, and to live in nursing homes.
The “old old” are more likely to need help. About 1% of those aged 65 to 74 live in nursing homes today; among those over age 85, that figure increases to 25%. Half of the “old old” need help with activities of daily living, while only 9% of those 65 to 74 require assistance.
As the population ages, demands for nursing care and nursing home placements should be expected to increase, both in absolute terms and as a proportion of all health care needs and spending.
Q & A
Q: The attending physician for one of our nursing home patients has recommended both “Do Not Resuscitate” (DNR) and “Do Not Hospitalize” (DNH) orders. The patient’s court-appointed guardian agrees. Our corporate policy seems to require that someone secure Court approval before the orders can be entered. Can this be the law?
A: No. Under Arizona law, a guardian has the power to make medical decisions for her ward, including the power to sign necessary consents and authorizations. In fact, it is clear (thanks to theRasmussen v. Fleming case) that a guardian can even authorize removal of feeding tubes in appropriate cases.
Arizona statutes do not specifically address DNR or DNH orders. There is provision, however, for a “Prehospital Medical Care Directive,” better known as the “orange form.” By executing an “orange form” a competent patient can express her wishes not to be resuscitated by emergency medical personnel, including paramedics. While this is not the same as a DNH order, it does address the same issues as a DNR. Both kinds of orders are “entered” by physicians, though consent of the patient, agent or guardian is required.
Guardians are specifically authorized to execute the “orange form” on behalf of wards. It is clear that a guardian has the power to make medical decisions generally, and the decision to approve a DNR or DNH order specifically.