For older people to be safely and effectively cared for at home by family members and caregivers, certain critical considerations need to be observed.
These range from appropriate national policies to support the provision of home care, the involvement and participation of hospitals and healthcare institutions in ensuring the right care processes are in place at home, training for caregivers, as well as emotional and social support to enable them to cope with the demands of looking after their elderly charges.
These were the recommendations outlined by a group of healthcare ethicists from the Centre for Biomedical Ethics (CBmE) at the Yong Loo Lin School of Medicine, National University of Singapore (NUS Medicine), the US, and the UK. They had recently concluded a three-year project on the societal challenges in Singapore that arise from the needs of ageing people, their families, and the healthcare and social care workforce.*
The report had funding support from the Lien Foundation and was launched in conjunction with an empirical study conducted by the NUS Social Science Research Centre. It takes into consideration Singapore’s existing social as well as health policies, including the ‘many helping hands’ approach articulated in Singaporean social policy and found in current structures and financing of programmes for ageing people, said Associate Professor Jacqueline Chin, the lead author. "The report considers how an ageing society should acknowledge, advance, and balance the interests of older adults and of caregivers, with an emphasis on the everyday context and setting of home and community.
By describing frameworks for understanding challenges like these, and focusing on the home as a crucial setting for the giving and receiving of care, the report’s authors want to support high-level reflection and discussion concerning social systems that support or hinder good care from being provided to seniors at home."
Summary of the Report’s recommendations
With the vast majority of elderly Singaporeans living at home, the definition of “good care” expands beyond healthcare to include aspects of everyday life.
A shared understanding of good care for older people in Singapore’s ageing society aims to help older adults live good lives, and to prevent problems that could cause suffering and harm to older adults as well as to caregivers.
Many people who give care to older adults at home are not professionals. Most are family members, domestic workers, neighbours, and community volunteers. While professional healthcare and social care workers are involved in care at home, there are limits to holding family members, domestic workers, or community members to professional performance standards. What, then, are the appropriate standards?
The report recommends that ethical standards for care at home be discussed by the public and among government and voluntary and private sector organisations broadly involved in the provision of care at home, including the housing, social services, manpower, and healthcare dimensions.
The standards proposed in this report aim to support the human relationships which sustain the care that adults growing older need in Singapore. They include:
- Supporting older adults’ agency (the ability to make and act on choices) and preventing harm, with attention to balancing independence and safety, respecting privacy in the home, and setting appropriate limits and expectations when healthcare is delivered in the home. For example, a shared understanding of good care at home can support older adults’ ability to continue to do things that provide them with dignity, meaning, purpose, or enjoyment. Among other things, this calls for adapting our environments to better support people with age-related conditions affecting mobility, eyesight, hearing, or cognition.
- Respecting and sustaining care relationships, in particular supporting primary caregivers and shared responsibility for care work within families, and supporting the formation of social networks around older adults who have care support needs. For example, while most care work is done or managed by women, typically adult daughters, many Singaporean women hold jobs and also have childcare responsibilities. National conversations should explore how caregiving responsibilities can be more fairly distributed between men and women, and among family members. They should include how people who are ageing alone can receive practical help and social support when they need these.
- Special considerations for caregivers who are foreign domestic workers, including protecting their welfare and rights in the work environment of the home. For example, programmes for caregivers should recognise and support domestic workers. Domestic workers’ perspectives should be part of efforts to improve care at home in Singapore. As the need for caregivers grows across ageing societies, how can care work in the home and in other settings be respected and supported as meaningful and worthwhile jobs?
- Reflecting in our public policy, preparedness for family life in an ageing society. This would include providing opportunities for sharing insights among peers, whether older adults, family caregivers, or domestic workers, so that people with common experiences and challenges may be strengthened by one another. For example, Singapore’s nation-building efforts in an ageing society ought to encompass understanding of a good life in later years.
Since care relationships in ageing societies are bolstered by a social system’s priorities, the authors also recommended that appropriate measures of progress in social care should be developed and refined over time.
- For example, national efforts to support good care at home through policy and investments in appropriate services should also ensure that older people and caregivers know about, and can readily gain access to them over the course of care.This includes reducing duplication, work done in silos, and gaps in services serving older adults at home that can lead to confusion and ineffectiveness at the community level.
- Older adults living in their communities also need access to social networks which are as important as health and social services. Ensuring training, supervision, and advisory support is necessary as more volunteer befrienders are recruited, said the authors. They noted that neighbours, hawkers, shopkeepers, and public servants play key roles in the social support of older adults, such as noticing unsafe situations or affording hospitable environments for older persons. Public education and outreach to this constituency can help strengthen this part of the social network.
And with medical technologies and clinical interventions finding their way into the homes of the elderly, caregivers will need help from professionals to understand and use these supports. Without these, “caregivers should not be blamed for care issues they cannot manage on their own,” the authors assert.
- To ensure an appropriate standard of care, hospitals may not only need to invest further in professional home care services but also identify clearer limits for the home as an extension of the healthcare system.
Turning their attention to Singapore’s reliance on migrant workers to provide care for the elderly at home, the authors highlighted ethical issues and responsibilities linked to social policy.
- These include appropriate recruitment practices, fair and non-exploitative terms of employment, training and job support, recognition, and advancement opportunities.
In addition, the researchers called for recognition and support for families who face multiple pressures in providing care to various parents and/or children at home while contributing to the workforce. “Public policy should address unresolved tensions between these competing obligations, given that leaving families to cope on their own is neither sustainable nor ethically sound,” they wrote.
- For example, information about financial responsibility for providing care in the home should be transparent. While families are encouraged to plan for the cost of healthcare in old age, they should also plan for their social care in old age. Clarifying the public provisions for social care is important for helping citizens to make the connections between good care and the good life.
Professor Vikki Entwistle, Director of the CBmE, thanked the Lien Foundation for funding the work and the authors for their insightful report. “The societal challenges of caring well for ageing people in their own homes are ethical as well as practical. At the Centre for Biomedical Ethics we look forward to working with policy leaders, service providers, older adults and those who care for them at home to help fulfil the recommendations made in this report and to continue the development of ethical thinking and practice in health and social care”.
“Society should not perceive all older people as a burden and differentiate between those older people who are frail, sick and need high level care, from those older people who remain healthy well into their 80’s and live in the community, and who most likely do not ever require any high level care such as nursing homes etc. When we keep saying ‘tsunami’ of grey hair or silver hair older Singaporeans … by 2030 etc, this is a message implying that all these older people will need institutional or intensive home care, rather than saying some will need high level care but most will stay healthy and require low level care, looked after by the GPs in the community,” said Professor Doris Young, Head of Family Medicine at the National University Health System. “If they do need care, it is society’s duty to look after them regardless of whether their family can do so or not. Society has to protect older people just like they do with children,” she added.
*The authors of this report are Associate Professor Jacqueline Chin from CBmE at NUS Medicine, Dr Michael Dunn from The Ethox Centre at University of Oxford, Dr Nancy Berlinger from The Hastings Center, and Associate Professor Michael Gusmano from The Hastings Center and Rutgers University. They are responsible for the analysis and recommendations offered.
See press release.