By Elizabeth Hsu CNA staff writer
Yeh Tzu-kang CNA staff reporter
Taiwan's new government has listed "long-term care" services as one of its key policies, refocusing attention on the question of how the country, with its rapidly aging population, will take care of seniors as their growing numbers stress the health care system.
Several challenges stand out in the discussion of long-term care. Who will pay for the services? How will they be delivered? Is there sufficient and adequately trained manpower to provide care? What should the roles of the public and private sectors be?
Beyond these broader questions, however, lies a more fundamental issue -- how to provide a high quality of care to incapacitated seniors who need constant attention and the degree to which they may have to be "restrained" to prevent harming themselves.
At most assisted-living facilities in Taiwan, it has long been common practice to use physical restraints to secure elderly patients to their beds or wheelchairs to prevent them from falling and getting injured.
Such measures are the result of both safety concerns and the limited manpower at care facilities.
But some in Taiwan, including Lin Chin-li (林金立), chief executive of the Yunlin County Senior Citizen Welfare and Protection Association, are hoping the country can embrace the global trend toward restraint reduction and move toward a "zero restraint" culture.
"Such restraints are like jailing seniors," Lin says, especially because many of them have suffered declines in their verbal communication skills and cannot express their discomfort.
Yao Chien-an (姚建安), who supervises hospice care wards at National Taiwan University Hospital, said that while "restraints" are rarely used on patients under hospice care, they are sometimes "a necessary option to prevent patients from hurting themselves or others."
Some patients, for example, will pull off the feeding tube from their nose unconsciously. "Repeatedly inserting the tube can be endless torture for both the patients and their family members," Yao said.
The restraint dilemma is one that care providers will battle with even more often in the future as the elderly population in Taiwan grows.
The National Development Council (NDC) has projected that Taiwan will become an aged society in 2018 (when more than 14 percent of the population is 65 and over) and a super-aged society by 2026 (when more than 20 percent of the population is 65 and over).
In terms of the aging index, which is calculated as the number of persons 65 years old or over per 100 persons under age 15, Ministry of the Interior statistics show that the index has risen from 51.4 to 91.6 in a 10-year period between November 2005 and November 2015.
The number of seniors in Taiwan is expected to surpass the number of people aged 14 or under for the first time ever in 2017, and there could be 4.1 times as many seniors as people aged 14 or under by 2061.
That year, the percentage of people 65 and over will account for 38.9 percent of Taiwan's population, compared with the 2016 level of 13.2 percent, according to the NDC.
During this dramatic demographic transition, meanwhile, the aged dependency ratio -- the size of the non-working population as a percentage of the working-age (15-64) population -- will rise from 36.2 percent in 2016 to a worrisome 94.6 percent in 2061, the council projected.
Also of concern is that while life expectancy in Taiwan averaged 80.2 years in 2015, the average number of years people were actually healthy was 71 years -- 68.7 years among males and 73.4 years among females -- according to Ministry of Health and Welfare data from 2014.
The figures suggest seniors need to rely on medical support or care given by other people for as long as eight to nine years to stay alive, and many of them require full-time care because of incapacitating ailments.
A growing elderly population needing an average of nine years of care means more people in nursing homes or care centers, and most likely more people tied down with physical restraints.
According to the government-approved standard contract for long-term care services, assisted living facilities are entitled to apply "appropriate restraints" to those in their care with the approval of the patients themselves or their families based on a medical diagnosis or medical history.
That partly explains why restraints are commonly used in Taiwan.
Lin believes, however, that part of the dilemma is a lack of manpower. Some care facilities, he says, believe it is safer to tie down seniors because if they fall and injure themselves, caregivers will have to spend more time attending to them or be condemned by family members.
But that may be missing the point, Lin says.
Confining seniors to a bed or wheelchair only worsens their physical condition, leaving even fewer palatable options for their care or helping them improve their quality of life, he contends.
Instead, Lin says, Taiwan should learn from Japan, which is already confronting a serious aging problem, and its move toward "care without restraints."
"Long-term care should not be seen as a sanctuary the elderly retreat to or as something that supplements a family's caregiving function. It should be to help seniors live independently, see themselves in a positive light, and enjoy their later years," Lin says.
And that means being as free as possible, without physical restraints, especially as experts see care models that use or don't use restraints as both having their risks.
"Being disabled in some way is not the same as being completely incapacitated," Lin says. "We don't want to see people restrained in their old age and in the end pass away while suffering a disability and being tied up."
※Related news include:
Elderly Care Dilemma (II): Making a case for 'zero restraints'
Elderly Care Dilemma (III) : Many obstacles to 'zero restraints'