Older Persons' Rights for Self-Determination in End-of-Life Decisions

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Older Persons' Rights for Self-Determination in
End-of-Life Decisions Abroad

• Sooyoun Han, PhD, MSW, Founder
• Care Rights (Republic of Korea)

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Table of Contents

• Problem Statements.... 3
• Increase of Ageing Migration in South
  Korea........ 5
• Lack of Awareness and Cultural Incompetency
  Regarding EOL
  
• Decisions in South Korea....
  6
• Identified Problems for Foreign Travelers and
  Foreign Nationality
• Residents. 9
• Care Rights Program Goals, Activities
  Outcome.. 12

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Problem Statements

• The phenomenon of rapid global ageing has led to
  challenges related to
• human well-being.
• The older population is itself ageing. Globally,
  the share of older persons aged 80 years or
  over (theoldest old) within the older
  population was 14 percent in 2013 and is
  projected to reach 19 percent in 2050.
• If this projection is realized, there will be
  392 million persons aged 80 years or over by
  2050 more than three times the present number
• (U.N. Department of Economic and Social
  Affairs, 2013)
• The number of international migrants worldwide
  reached 232 million,
• up from 154 million in 1990. The global
  population of international migrants is
  growing at a rate of about 1.6 percent per year
  (U.N. DESA, 2013).

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Figure. 1. International Migration, 2013
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Figure 2. Age distribution of international
Migrants, 2013
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Figure 3. Eight-Point Agenda for Making Migration
Work
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Problem Statements

• Numerous potential obstacles for foreigners in
  need of EOL
• care abroad are seen, including
• Absence of EOL decision processing for
  foreigners
• Differences in cultural and healthcare
  legislation regarding
• patients autonomy between two countries
• Language barriers
• Such problems could lead to
• Disparities in the decision-making process
  regarding EOL care
• Violation of human rights
• Elder abuse in crisis situations, including
  stranded migrants
• Unnecessary medical expenditures

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Increase of Ageing Migration in South Korea

• Return migrants persons returning to their
  country of citizenship after
• having been international migrants in another
  country and who are
• intending to stay in their home country for at
  least a year
• (U.N. Division for collecting data on
  international migration, 1998).
• In 2011, 2,128 people reverse migrated to South
  Korea from the U.S. the largest population
  of reverse migrators to South Korea overall.
• (Korean Ministry of Foreign Affairs, 2012).
• 95,234 American Nationals aged 60 years or older
  entered South Korea in 2011 14,708 of them
  remained in the country three months or longer
• with registered foreigner status from the U.S.
  (Han, 2012).

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Lack of Awareness and Cultural Incompetency
Regarding EOL Decisions

• 1. Family Norms and Patients Autonomy
• on EOL Decisions in South Korea.
• Cultural ideas and expectations for family
  caregiving play a crucial role
• in the EOL decision process Many Asian
  countries find such discussions
• taboo and against filial piety.
• Often, elders do not understand the concept of
  patient autonomy and EOL
• decisions are relegated to family caregivers
• (Haung, Hu, Chiu, Chen, 2008 Kwon 2010).
• As a result, Korean healthcare staffs are not
  trained in EOL communication
• skills for EOL decision making processing (Han
  Lee, 2013).

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Lack of Awareness and Cultural Incompetency
Regarding EOL Decisions

• 2. Lack of
  Hospice Services and Social Services
• for EOL Decisions in South Korea.
• Lack of legal and social services raise the risk
  of misconduct and/or
• neglectance in EOL processes, leaving
  insufficient EOL decisions that
• could lead to elder abuse in the forms of
  neglect, inequality, and
• discrimination.
• Foreign travelers or residents are vulnerable to
  have possibly unwanted
• aggressive treatments, as opposed to
  pre-requested EOL decisions that are
• culturally-designed, pain-free and provided by
  comfortable hospice care.

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Lack of Awareness and Cultural Incompetency
Regarding EOL Decisions

• 3. Healthcare Legislature and Patients Autonomy
  Regarding EOL Decisions in South Korea.
• Legislation such as the U.S.s Patient
  Self-Determination Act (Pub. L. No. 101-
• 508, PSDA), which calls for Advance
  Directives for Health Care, but not yet
  enacted in South Korea.
• As of now, the South Korean Emergency Medical
  Service Act (EMSA)
• requires that hospitals and healthcare
  providers provide mandatory emergency
• medical services to all patients, contingent
  upon certain disparities.

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Identified Problems for Foreign Travelers and
Foreign Nationality Residents

• 1. Conflicts Between Legal and Health Insurance
  Systems
• The Korean government founded the Emergency
  Service Fund (ESF) to
• reimburse unpaid expenses to medical service
  providers (Song, Kim Lee,
• 2008). One fourth of this fund was paid for by
  foreign emergency patients.
• Most travel insurance plans have a max. coverage
  cap and do not always
• cover all options for life-sustaining
  treatments.
• Public insurance like Medicare does not cover
  medical costs abroad others
• cover only partial medical costs.

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Identified Problems for Foreign Travelers and
Foreign Nationality Residents
1. Conflicts Between Legal and Health Insurance
Systems (continued)

• Issues such as unwanted life-sustaining
  treatments for those with
• completed Advance Directives for Health Care
  may arise due to
• responsibility of expenses and national and
  international legal issues.
• Reasons for such problems include
• Lack of clear and culturally-sensitive
  information
• Deficits in health care legislation
• Lack of legislation for self-determination of
  EOL decision in some countries
• Cultural differences and language barriers

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Identified Problems for Foreign Travelers and
Foreign Nationality Residents

• 2. Violation of Human Rights
• Foreign travelers and/or residents are at a
  higher risk for misconduct and/or
• neglectance in EOL care left with insufficient
  EOL decisions that could form
• another type of elder abuse abroad.
• Foreign travelers and/or residents are easily
  deprived of rights to being informed about
  self-determination at EOL care in abroad.
• In South Koreas current state, the rights of
  foreign travelers and/or residents
• who do not wish to receive aggressive
  life-sustaining treatments cannot be
• protected if unable to make EOL decisions at
  the time of service.

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Program Goals
Care Rights is working

1. To prevent neglect, abuse, and the violation of
   human rights of older persons in their EOL care
   in South Korea.
2. To ensure human rights are met by allowing older
   adults who are foreign travellers or foreign
   national residents to make EOL decisions in
   advance with the benefits of cultural sensitivity
   and competent language services.

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Program Goals
Care Rights is working

• To reduce misconduct in life-sustaining
  treatments caused
• by a lack of health legislation,
  communication, and educational
• materials about EOL care and the rights of
  foreign travellers and
• foreign nationality residents.
• To provide a psychoeducational intervention
  program to reduce
• the tremendous emotional and psychological
  burdens of long-
• distance family caregivers, as well as
  healthcare providers and
• staffs.

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Program Target Population

• Care Rights Target Populations
• Foreign travellers and foreign nationality
  residents in South Korea
• Long-distance family caregivers of foreign
  travellers and foreign
• nationality residents in South Korea
• Health care providers and staffs who provide
  emergency medical
• services to patients who are foreign
  travelers and/or foreign
• nationality residents

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Program Activities

• Care Rights Activities
• Provide a psycho-educational intervention
  program for older persons
• who are foreign travelers and/or foreign
  nationality residents and
• their caregivers about end-of-life care and
  rights in South Korea
• 2. Implement National Advance Directives for
  Health Care Form and
• provide them to foreign travelers and
  foreign nationality residents on
• a regular basis.
• 3. Educate healthcare workers and social workers
  about EOL decision
• processing, and publicly advocate the rights
  of elderly patients in their
• autonomy in EOL decisions.

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Program Activities

• Care Rights Activities
• Develop brochures and materials about the rights
  to EOL decisions,
• National Advance Directives for Health Care
  Form, and cultural
• supports to ensure that foreign travelers
  and foreign nationality
• residents are aware of their rights and do
  make decisions regarding
• their EOL care
• Work collaboratively with the Korean Ministry of
  Foreign Affairs
• and National Immigration Service to provide such
  materials and
• services to foreign travelers and foreign
  nationality residents visiting
• South Korea.

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Care Rights Program Outcome

• Care Rights Outcome
• Protect older foreign travelers and foreign
  nationality older
• residents rights to EOL decisions abroad,
  ensured by the Madrid
• International Plan of Action on Ageing,
  2002.
• Improve older persons dignity and autonomy in
  the process of
• dying.
• Lighten stress and burden of long-distance family
  caregivers,
• including those who are located abroad.

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Program Outcome

• Care Rights Outcome
• Reduce unnecessary medical expenses incurred by
  misconduct and neglect that go against the rights
  of foreign older travelers and foreign
  nationality older residents in their EOL
  decisions.
• Develop International Older Persons Human Rights
  Instruments for EOL decisions and well-dying
  processing, focused on one of the main areas of
  concern for the lack of special measures,
  mechanisms and services (The Second Assembly on
  Ageing, A/66/173, 2011).

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References

1. UNDP(2013). Population Prospects, 2012 Revision.
2. U.N. Department of Economic and Social Affairs
   (2013). World Population Polices 2013. New York
   U.N.
3. U.N DESA. (2013). World Population Ageing 2013.
   New York U.N.
4. United Nations (1998). Statistics Division for
   collecting data on international migration.
5. Korean Ministry of Foreign Affairs (2012)
   Diplomatic White Paper. www.mofa.go.kr/ENG/pol
   icy/whitepaper/index.jsp?menum_20_160
6. Han, S. B. (2012, 05 03) Rush of reverse
   migration due to expensive medical cost in
   abroad. Seoul Newspaper http//www.seoul.co.kr/
   news/newsView.php?id20120503010010.
7. Huang, C-H., Hu, W-Y., Chiu, T-Y., Chen,
   C-Y.(2008). The practicalities of Terminally Ill
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8. Kwan, Iro Bae, H.A. (2011). A Narrative
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   J of Korean Medicine Ethic, 14(2). 157-170.
9. Han, S. K. Lee, H.J.(2013). A Discussion on
   Elderly Patients and their Family Caregivers
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10. Song, K.M., Kim, Y. S., Lee, Y. H. (2008).
    Legalistic Study of the Subrogation Payment in
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11. UN, Economic and Social Council (2012). Report
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    Substantive Session

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