Responsibilities in elderly care: Mr Powell's narrative of duty and relations

In Western countries a considerable number of older people move to a residential home when their health declines. Institutionalization often results in increased dependence, inactivity and loss of identity or self-worth (dignity). This raises the moral question as to how older, institutionalized people can remain autonomous as far as continuing to live in line with their own values is concerned. Following Walker's meta-ethical framework on the assignment of responsibilities, we suggest that instead of directing all older people towards more autonomy in terms of independence, professional caregivers should listen to the life narrative of older people and attempt to find out how their personal identity, relations and values in life can be continued in the new setting. If mutual normative expectations between caregivers and older people are not carefully negotiated, it creates tension. This tension is illustrated by the narrative of Mr Powell, a retired successful public servant now living in a residential home. The narrative describes his current life, his need for help, his independent frame of mind, and his encounters with institutional and professional policies. Mr Powell sees himself as a man who has always cared for himself and others, and who still feels that he has to fulfil certain duties in life. Mr Powell's story shows that he is not always understood well by caregivers who respond from a one-sided view of autonomy as independence. This leads to misunderstanding and an underestimation of his need to be noticed and involved in the residential community.     

Autonomy and competency--self-determination in the lives of adults with developmental disabilities

The principle of autonomy anchors decision making for most North Americans. For people with disabilities, however, the quest for self-determination is often countered by society's responsibility to take care of those who have some area of weakness or incompetence. Those who serve this population must, therefore, intentionally shift the balance of power to encourage independent living and to give people with disabilities a voice in their own lives. Changes in the system of care, training, and the way questions of competency are adjudicated are contemplated.     

A care perspective on coercion and autonomy

In the Netherlands there is a growing debate over the possibility of introducting 'compassionate interference' as a form of good psychiatric care. Instead of respecting the autonomy of the patient by adopting an attitude of non-interference, professional carers should take a more active and commited role. There was a great deal of hostile reaction to this suggestion, the most commonly voiced criticism being that it smacked of 'modern paternalism'. Still, the current conception of care leaves us with a paradox. On the one hand patients are regarded as individuals who have a strong interest in ( and a right to) freedom and non-interference; on the other hand many of them have a desperate need for flourishing, viable relationships. In fact, part of their problem is that they cannot relate very well with other people. This creates a dichotomy, because respecting patients' autonomy often means that they cannot be given the help they so desperately need. In this respect current care practices do not answer the caring needs of these patients.The criticism on care practices is to be considerd as important. It invites us to reexamine and reevaluate the current conception of caring relationships and its main values. In line with this reexamination an alternative perspective on care is introduced in this paper, a perspective in which `compassionate interference' is not so much a threat to autonomy, but a means of attaining autonomy. For this we need a different definition of autonomy than that commonly used in current care practice.     

Community care and social services.

The aim of community care is to enable people with various types of disability to live in their own homes, rather than in institutions. This involves the provision of support and services at home by various agencies. After a critical report in 1986 identified problems with coordination and flexibility of community care services, the white paper Caring for People (1989) stated the government''s aim to provide a "needs led," responsive range of services, promoting maximum independence of those wishing to live at home rather than enter institutional care. New arrangements were introduced in 1993, involving a formal assessment procedure and the production of a personalized care plan for each individual, incorporating services provided by private and voluntary agencies as well as by social services departments. This article describes the components of community care services supplied by local social services authorities, including housing adaptations, equipment, telephones and alarms, home care, meals, and respite care.     

Homes and housing for elderly people.

Most elderly people in Britain live independently in their own homes. Moving to alternative accommodation may be necessary for some people but requires careful consideration. A multidisciplinary assessment should be performed when a person plans to move into residential care; this should include the input of a doctor trained in geriatric medicine. A range of housing options is open to elderly people and these options are discussed here.     

Community care for the elderly 1976-84.

The aging of the elderly population is of crucial importance as people who are over 80 make far greater use of health and social services than any other age group. Government guidelines on the provision of services, which are generally related to the whole population aged 65 and over, fail to take account of this change in the age structure of the elderly population and are no longer appropriate. Recent trends in the provision of domiciliary services, day care, specialist housing for the elderly, and residential care have been related to changes in the number of potential consumers. Ironically, despite the government''s stated commitment to "community care," the chief growth area has been private institutional care. The number of day care places and sheltered housing units has also increased in real terms, but the provision of domiciliary services, such as home help and health visitor visits to the elderly, has either fallen behind or barely matched the increase in the number of very old people. If community care is to be made a reality and if the present inadequate levels of service are to be maintained, let alone improved, then additional resources, greater cooperation among agencies, and a more imaginative approach to the development and delivery of services are urgently needed.     

The Karamazov complex: Dostoevsky and DNR orders

Families making difficult end-of-life decisions in the intensive care unit often do not exercise their autonomy in accord with the individualistic philosophic and legal models that currently prevail. Instead, they try to avoid responsibility and deny complicity, even for decisions that they ultimately approve. This paper examines two novels and a recent case from a neonatal intensive care unit that reveal how people actually make tragic decisions for family members. Dostoevsky's The Brothers Karamazov and Kenzaburo Oe's A Personal Matter explore the patterns of communication by which people in such situations test complicity and share or submerge accountability. The psychological similarities between the novelists' portrayals and the actual processes that families undergo in the ICU have practical clinical implications for the ways physicians approach discussions about do not resuscitate (DNR) orders with patients' family members.     

Environmental enrichment for laboratory rodents and rabbits: requirements of rodents, rabbits, and research

Environmental conditions such as housing and husbandry have a major impact on the laboratory animal throughout its life and will thereby influence the outcome of animal experiments. However, housing systems for laboratory animals have often been designed on the basis of economic and ergonomic aspects. One possible way to improve the living conditions of laboratory animals is to provide opportunities for the animals to perform a species-specific behavioral repertoire. Environmental enrichment should be regarded both as an essential component of the overall animal care program and equally important as nutrition and veterinary care. The key component of an enrichment program is the animal staff, whose members must be motivated and educated. It is critically important to evaluate environmental enrichment in terms of the benefit to the animal by assessing the use of and preference for a certain enrichment, the effect on behavior and the performance of species-typical behavior, and the effect on physiological parameters. At the same time, it is necessary to evaluate the impact on scientific outcome, how the enrichment influences the scientific study, and whether and how the statistical power is affected. The result will depend on the parameter measured, the type of enrichment used, and the animal strain. In this article, goals of enrichment are defined and discussed. Animal behaviors and needs are described, along with the translation of those needs into environmental enrichment programs. Specific types of environmental enrichment are outlined with examples from the literature, and an evaluation of environmental enrichment is provided.     

Helping disabled people--the user's view.

The main needs for most people with physical disabilities are housing and help with daily living. Thus, many of them will find the new emphasis on social aspects of community care particularly relevant. Peter Swain is a disabled man who leads a project in east Devon which ensures that disabled people have a voice in helping to shape the services they need. In this article he explains how the project, Living Options East Devon, works and how the new legislation for community care might affect disabled people.     

CIRDO: Smart companion for helping elderly to live at home for longer

Cirdo project is intended to establish new healthcare systems to ensure the safety at home of seniors and people with decreasing independence. In particular, extending “e-lio footnote http://www.technosens.fr/” devise, Cirdo aims to develop an audio/video-based system which makes it possible for elderly to live with a sufficient degree of autonomy. To achieve this goal, generic purposes on video analysis and audio processing are discussed and implemented in the same process. Audio and video analysis algorithms are launched simultaneously and thinks to GPU implementation, the tasks are done in real time. To comply with the requirements set out in the Cirdo project namely: respect privacy and preserve personal data, the processing tasks is performed through background tasks, without any human intrusion. In order to have different types of fall for our experiences, multiple scenarios were designed and performed by several persons. Besides the technical aspect, the project also focuses on generic technology validation by potential users and their human environment (family, caregivers/care takers…). Psychological and ergonomic assessment on the use of services developed was conducted. It focused on the usefulness, usability and accessibility and acceptance of the tool. This evaluation was completed by critical investigation of knowledge acquired by professionals (geriatricians, caregivers school and associations).     

Deciding on Death: Conventions and Contestations in the Context of Disability

Conflicts between bioethicists and disability theorists often arise over the permissibility of euthanasia and physician assisted suicide. Where mainstream bioethicists propose universalist guidelines that will direct action across a range of effectively disembodied situations, and take for granted that moral agency requires autonomy, feminist bioethicists demand a contextualisation of the circumstances under which moral decision making is conducted, and stress a more relational view of autonomy that does not require strict standards of independent agency. Nonetheless, neither traditional nor feminist perspectives have fully engaged with the critique of disabled people that they are consistently subjected to discriminatory, even life-threatening, practice and policy in biomedical and health care. The paper revisits some of the issues that drive the often highly polarised debate between bioethicists and disability theorists around the question of end of life decisions involving disabled people. While many bioethicists have doubtless been indifferent to the difference that disability makes, I am also concerned that the very proper demand of disability activists and theorists to scrutinise all end of life decisions for signs of discrimination and even violence has segued into something damagingly restrictive that silences internal dissension and stifles external debate. Given that euthanasia and physician assisted suicide may be issues where conventional argument on either side will founder on deeply felt convictions, I make the radical move to speculate on an entirely different, quasi-Deleuzian, approach to the value of life in order to shake up entrenched positions, and begin to think differently.     

The environment of ageing.

The issue of housing and the wider environment for an ageing population is one where there are many unanswered questions. In this paper a number of key issues are discussed and for each of these the focus is on three aspects. These are the current situation, its reasonableness and what research is needed in order to make decisions about policy and practice. The first three issues relate to the profile of older people themselves and the importance of home to them. The changing profile of older people is not just about an ageing population but also about the growing prominence of those with dementia, women, people from black and ethnic minority groups and one person households, yet little is known about the type of housing which should be provided. Of equal concern is the widening gap between those with a high standard of living (including housing) and those with a low standard of living. The importance of home to older people means that research must focus on how people can be enabled to remain there, and also on the costs, financial and otherwise, to carers and to society. The next three issues relate to the type of housing older people live in and moves in later life. The startling change in the tenure pattern with a growth of owner occupation brings problems as does the decline in social housing. The advantages and disadvantages of the different types of housing--mainstream and specialized--for older people are relatively well known. However the balance between the two needs more research as does that on retirement communities. While it is well known that there are peaks of migration in old age and that moves are often made in haste, little is known about the process of decision making. The final two topics concern links between housing and other aspects of older people''s lives. On health more research is needed on temperature, mortality and morbidity, homelessness and accidents and especially on links between services. These topics have implications for planning and design. The emphasis should be on a multidisciplinary approach using a variety of quantitative and qualitative techniques with an emphasis on dissemination.     

The Spillover Effect of a Flood on Pets and Their People: Implications for Rental Housing

When disasters strike, companion animals (pets) matter. Emergency planning for them is a key aspect of disaster preparedness, especially considering that people may delay evacuation out of concern for their pets. Temporary boarding options for pets are important; however, caregivers (owners) must ultimately return to permanent housing. Surprisingly little attention has been paid to housing recovery in the disaster literature on pet ownership, and no studies have examined the potential for increased vulnerability among tenants with pets. This study analyzed online rental listings in a city that was severely flooded in 2013. In the following year, demand for pet-friendly rental housing outweighed supply. Landlords frequently stipulated restrictions on the allowable sizes, species, or breeds of pets. Dogs were often banned outright. To keep their pets, prospective tenants needed to exercise flexibility in location and pay higher surcharges. The implications of housing insecurity for tenants with pets have broad relevance, not just in disaster circumstances. Giving up a companion animal to secure housing can negatively impact resilience, whereas living in unsafe environments to avoid pet relinquishment may increase vulnerability.     

The development of infant-caregiver relationships in captive common marmosets (Callithrix jacchus)

The growing independence of infant common marmosets from their caregivers is promoted primarily by their caregivers, who increasingly often prevent the infants from climbing onto them and decreasingly often pick the infants up. Infants achieve independence from their mothers, fathers, and older siblings at different rates and develop characteristically different relationships with them. Infants that are most rejected by caregivers spend the least time on them. When rejected by their parents, infants tend to spend their time with their twins, rather than seeking to climb onto other caregivers. Caregivers do not compensate for unduly large or small amounts of care given by other members of the group. It is argued that if we are to understand the development of caregiver-infant relationships in species with multiple caregivers, we must discover the rules by which infants assess the amount of care they perceive themselves to have received and caregivers assess the amount of care they perceive themselves to have offered. The implications of a simple model based on expected levels of caregiving and careseeking are explored, particularly with respect to competition and compensation.     

Theme D: Sensors,wearable devices,intelligent networks and smart homecare for health

This paper presents the activities of the research group in sensors, wearable devices, intelligent networks and smart homecare for health inside the GdR STIC-Santé. Four research fields are covered: sensors, clothing, housing and networks, to allow better monitoring of health parameters and quality of life. Several events were organized or co-organized during the period 2011–2102. They were devoted to the issue of the autonomy of people with a particular focus on the needs and expectations and also the embedded technologies developed to enable monitoring of health parameters and activities in their living environment. Future projects will try to complete the knowledge of the current work on frailty and the risks incurred, in particular falls, and identify opportunities to share the achievements of the research teams to respond to National or European projects calls.     

The Individualist Model of Autonomy and the Challenge of Disability

In recent decades, the intertwining ideas of self-determination and well-being have received tremendous support in bioethics. Discussions regarding self-determination, or autonomy, often focus on two dimensions—the capacity of the patient and the freedom from external coercion. The practice of obtaining informed consent, for example, has become a standard procedure in therapeutic and research medicine. On the surface, it appears that patients now have more opportunities to exercise their self-determination than ever. Nonetheless, discussions of patient autonomy in the bioethics literature, which focus on individual patients making particular decisions, neglect the social structure within which health-care decisions are made. Looking through the lens of disability and informed by the feminist conception of relational autonomy, this essay argues that the issue of autonomy is much more complex than the individualist model suggests. The social system and the ableist ideology impose various forms of pressure or oppressive power that can affect people’s ability to choose according to their value system. Even if such powers are not directly coercive, they influence potential parents’ decisions indirectly—they structure their alternatives in such a way that certain options are never considered as viable and other decisions must be made. This paper argues that, instead of only focusing on the individual act of decision-making, we need to pay attention to the social structure that frames people’s decision.     

The effect of women's status on infant and child mortality in four rural areas of Bangladesh

In South Asia women are often the primary decision-makers regarding child health care, family health and nutrition. This paper examines the proposition that constraints on women's status adversely affect the survival of their children. Survey data are used to construct indices of women's household autonomy and authority, which are then linked to longitudinal data on survival of their children. Proportional hazard models indicate that enhanced autonomy significantly decreases post-neonatal mortality. Enhanced household authority significantly decreases child mortality. A simulation based on estimated effects of eliminating gender inequality suggests that achieving complete gender equality could reduce child mortality by nearly fifty per cent and post-neonatal mortality by one-third.     

The Canadian Institute of Aging: knowledge, innovation and action

Led by innovation, leadership, transparency and excellence, the Institute of Aging provides a focal point for Canadian research on aging and pursues the fundamental goal of advancing knowledge in the field of aging to improve the quality of life and health of older Canadians. The Institute has carried out a range of important national and international strategic initiatives in aging, and has become influential in leveraging funding, enhancing research capacity and creating a new impetus in research on aging in Canada. The Institute engages and supports the scientific community, encourages interdisciplinary and integrative health research and fosters not only on the creation of new knowledge, but also on the translation of that knowledge into improved health, a strengthened health care system, and new health products and services for Canadians. The IA focuses on five priority areas of research: healthy and successful aging, biological mechanisms of aging, cognitive impairment in aging, aging and maintenance of autonomy, and finally, health services and policies relating to older people. The efforts of the IA are guided by five strategic orientations: to lead in the development and definition of strategic directions for Canadian research on aging ; to build research capacity in the field of aging ; to foster the dissemination, transfer and translation of research findings in policies, interventions, services and products ; to promote the importance of, and the need for, a research community in aging ; and to develop and support capacity-building and strategic research initiatives in the field of aging.