There are a number of ethical issues which concern our elderly population which over the years need re-looking at. One cannot in all honesty say that over the past two decades, not a lot has been done.

When one considers the number of homes which have risen, the re-vamping of what was formerly called ‘Has-Serh’, or the degrading name of ‘Tax-Xjuh’, or ‘L-Imgieret’, and not least the creation of a specialised medical hospital, Zammit Clapp, which continues to set examples and standards much to be envied, one realises that we have moved forward. Yet there are always vacuums to fill and one considers progress by what one is doing at the present moment.

Perhaps the most pertinent question is homes. It is policy, and one which should remain, at that, that as much as possible the elderly should be kept in the community. There is much more than meets the eye in this under-rated statement. We are not only speaking about a social service here but a complete biopsychosocial one. The psychological well-being is perhaps the most pertinent. While in homes, one is taken away from one’s environment and friends, new friends are made and there is continual nursing care. In the community one often finds elderly living on their own, with relatives visiting less and less often, that they have to rely on neighbours. Cognitive function does not remain the same; one patient comes and goes to the pharmacy and my clinic about five times each time she needs a valium prescription. She forgets the control card which both doctor and pharmacist need to fill in. Of course the pharmacist will not release the medication without the card and my signature. Cannot we find an easier way to release controlled amounts of medication for those who live alone and are above 80? If one is concerned about abuse, this can still happen when one has a card. We need to re-think the comfort and convenience of our elderly population before we think about homes. In the long run it will serve us well as it will avoid all our elderly applying for admission to a home.

Conversely it is sad when one sees families trying to keep their parents with them at home. One daughter wanted her mother to remain with her; her elder brother did not want her there because he had had a row in the past with this daughter’s husband. He would not visit his mother at the house under any circumstance. He preferred having her in a home, and spoke to a minister about it, so that everyone would visit her in their own time. The other four brothers and sisters knew that his solution was not in the best interest of their mother and individually all wanted her to remain with their sister. But like a pack of dogs which follow the leader, they all gave in to his persistence. The result is that she died depressed and confused in a hospital bed – when she needed hospitalisation, he would not allow his sister to take her back home and used the abusive pressure to leave her in hospital against the doctor’s advice. We unfortunately have a lot of these cases, and families have learned how to use this sort of pressure to admit their relatives to homes. But if this is the only window, we may need to re-think the cause.

Instead of thinking homes for the elderly we should think elderly at home. One solution would be to use incentives for the sons or daughters who take on their parents. Certainly taking an elderly person into the home costs much in electricity, washing, cooking, nursing and doctoring, let alone space. So one can legislate the right that the pension be transferred to the person taking care. Although some siblings may find objection to this, a board can certainly assess the case and take a decision in the best interest of the person. A minister once pointed out some legal issues; but legal conundrums are there to be solved.

When we speak of elderly people we tend to converge only on the social issues of homes. There is also the biological and psychological well-being involved. Community services are one of them. I have often spoken of the lack of services such as physiotherapy, and occupational therapy in the community. If one had to make a statistic, I believe that eliminating rehabilitation for fractures, it is the elderly who use these services most.

Yet consider this scenario, which is surely familiar to most family doctors. An elderly person suffers a stroke. After a few weeks in hospital she is discharged home and given out-patient appointments for physiotherapy, occupational therapy and if necessary speech therapy. Yet for each of these appointments, people who do not have transport – and most do not because the rest of the family work during the day – have to get up early to get picked up at seven in the morning.

They then are taken for a two-hour or longer drive to pick up other people in the same condition. They wait in the waiting-room for another hour or more; are seen for 30 minutes and then wait again for two hours to be transported back home – another ordeal of an hour and a half or more. They arrive home after 1pm (for a half hour visit to a physiotherapist) and it is indeed providential that they survive the event and do not get another stroke.

The invariable happens: after one or two visits they give up. If they do not have the money to do things privately, the morbidity remains and an eventual second stroke may ensue, which in turn taxes our health services. Had we been more astute in rehabilitation we would have saved the patient and some of our resources. A pilot study in an area can easily prove this. With the help of the government we can easily carry out this study from the Department of Family Medicine. The solution is simply putting these services in the community, where appointments are easier, closer to the patient, and transport less of a problem. Less morbidity and handicap will mean more independence (and fewer applications for homes).

When it comes to hospital care we have done wonders with Zammit Clapp Hospital. It goes to show how much, given the right conditions, the Maltese provide excellent services. Changing the ergonomics of the main hospital (from St Luke’s to Mater Dei) has already improved the morale of many; but what makes Zammit Clapp special is the service they provide. They hold weekly meetings and discuss each patient personally. Seeing the interaction of doctors, nurses, physiotherapists, occupational therapists and speech therapists is a lesson in itself. Decisions are taken collectively and one sees teamwork, not only in the ward, but around a table over a coffee and a light atmosphere where each one puts in his or her input, giving the holistic approach which all patients deserve. Of course when it comes to sending people back home they do house visits to assess the situation, but once out of hospital they know only too well how difficult it can be to reach out to them.

A complementary service extended into the community, as we have with the Diabetic clinic, will do wonders first and foremost for patients, but also for our resources in the long run. Why all elderly patients cannot receive this service still eludes me. If Zammit Clapp has one fault it is that they seem not to have sent across the message to the authorities of what they actually do. Like most humble people and services, those who do not blow their trumpets go unnoticed. They have now been dumped at the former hospital and were greeted with a writing on the wall saying ‘now it is your turn’ (to be there, presumably). But slowly, given the resources, this place will turn into another Zammit Clapp. It is hoped that whoever wrote that, will not turn Mater Dei into the dump he left behind. It is all too easy to blame authorities when we are often responsible for the caring.

Last but not least we need to create a bioethics culture. We have been giving lip service to the concept of Advance Directives, for example, whereby people write out, with the help of their family doctors, instructions on how they wish to be treated (or not treated) when they are no longer capable of making decisions on their own. In these documents one may also select someone who will have a power of attorney – the right to make decisions on their behalf – and to whom doctors can look legally. I know of too many cases where an elderly person wishes for his personal doctor or a son or daughter to make the final decision about his or her health care, only to be over-ridden by over-powering cockatoos in the family.

These situations are painful for the patient, for the doctor, and not least for the person entrusted with the responsibility. Sometimes pressure is put on the elderly persons themselves – to receive treatment, for example, which they otherwise would not have wanted. In one particular case, a relative who was a doctor working abroad, pressured the patient to receive the state-of-the-art treatment, which he duly procured from abroad, but which the patient clearly did not want. His doctor was overwhelmed but there was nothing he could do. Clearly there was good-will involved; but ethically, the misconduct was appalling.

We have a Parliamentary Secretary for the Elderly. The political pressure he has to deal with is probably unimaginable. We can remove much of this pressure and allow him to work on more important issues if only we were to provide him with the resources to have someone look into these ethical issues. It is a pity that such a resource uses much of its time on social issues only. We have done a lot for our elderly, considering, but given there are headaches, there is still room for improvement.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta