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Healthcare's Rural Realities


Healthcare's Rural Realities
Biomedical dilemmas confront medical practitioners treating patients far from urban areas

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In Maine, many rural areas are defined not by name, but by their township and region numbers.

Directions often don't include street names or route numbers, but rather rely on landmarks familiar to those who live there, such as the Jones farm and the old general store.

This lifestyle, so treasured by Mainers, often creates complications when it comes to accessing medical care. Increasingly, the question has become whether you can get there from here.

"There are the same ethical questions (as in big cities), but Maine's different because of its rural location and small towns," says University of Maine Associate Professor of Philosophy Jessica Miller. "Rural and urban areas share many ethical issues in healthcare, but some issues, like conflicts presented by overlapping relationships, are unique to rural settings. And others, like access to healthcare, can be more pressing in rural areas due to geography or economics."

Maine may be one of the least racially diverse states in the nation, but socioeconomic and cultural differences abound from Fort Kent to Bangor to Kittery. Providing appropriate healthcare to the residents of the region oftentimes is complicated by financial and employment status, family circumstances and the Maine tradition of independence.

As a result, healthcare providers find themselves having to help patients weigh the feasibility of pursuing high-end medical treatment often available only a long way from home and their support systems, versus more reasonable treatment available locally that would be sufficient for the patient's desired quality of life. The latter often requires less extensive follow-up care or travel.

These are issues that Miller, whose research focuses on ethical issues in healthcare, finds intriguing. They are circumstances that aren't often considered in bioethical discussions and studies that mostly focus on urban settings.

"It's too bad that most bioethics researchers and scholars assume an urban setting because they miss out on unique needs and challenges of doing bioethics in a more rural area," Miller says.

Miller has been able to incorporate her interest in medical ethics and rural healthcare into her work, both on campus when teaching biomedical ethics, and off campus in Bangor as Eastern Maine Medical Center's clinical ethicist.

Part of the problem is ensuring that people have access to healthcare, which is a struggle that the entire country is facing with more than 47 million people now uninsured, but Miller says there's more to making people healthy than going to a doctor. Even if someone has health insurance, it doesn't mean he or she has access to proper healthcare services.

"Nobody is really happy right now with the current system, and that's something I've seen change in the last 10 years," Miller says. "The United States spends a lot of money on healthcare, and the returns aren't that great."

Miller says providing basic healthcare to all residents is a start to improving the system, but it isn't the magic bullet to better health.

"We know, for example, that unemployment is associated with worse health, regardless of access to healthcare. It has to be something else, not just providing more access to healthcare," Miller says. "We need to look at the social determinants of health."

For example, what happens when a patient who lives alone in the woods is ready to be discharged from the hospital with a post–recovery regimen that is difficult to self-administer? What's best for the patient in this situation?

When a primary care physician in rural Maine retires or relocates, an already overstressed system has to absorb hundreds more patients. All the health insurance in the world won't help if you can't find a doctor who is taking new patients, Miller says.

Researchers are beginning to understand that social status and factors not directly related to a person's immediate health are part of the healthcare crisis of America.

"There's a lot more than just healthcare to promoting health," Miller says.

Providing equal and ethical healthcare can sometimes be a challenge. That's why Eastern Maine Medical Center created an Ethics Advisory Committee in 2006, and more recently hired Miller as the on-staff clinical ethicist.

"We're not the ethics police. We don't make decisions but rather facilitate decisions made by patients, families and providers," Miller says of the committee.

Instead, the group uses its expertise to come up with possible options for the caregiver, the patient and often the patient's family.

In addition to case consultation, the committee members are responsible for educating themselves and the hospital staff on ethical issues in healthcare, as well as helping to review and draft policies.

"We're an advisory panel only. We're interested in getting the most ethical outcomes in patient care," Miller says. "We're really focused on the patient."

But providing the best options to doctors and patients can be difficult, particularly when there are circumstances outside what is medically best for a patient that play a role in the final decision making process.

In Maine, one of those concerns is that families many times have to travel long distances just to get to the hospital. If a relative has to go out of state for care, it might be impossible for family members to go with him or her.

Who will run the farm? Who will pay for the gas and hotel room? Who will take care of the children or ailing parents who have to stay behind?
In some cases, the most ethical option and final decision of the patient, caregiver and family might not be the most medically advanced, but in the end is the best outcome.

For example, there is no outpatient care in Maine for someone on a ventilator, requiring patients to go out of state.

Families many times have to travel long distances just to get to a hospital.

A one-way trip from Presque Isle to Bangor is roughly 160 miles. A patient coming from Fort Kent has a one-way trip of nearly 200 miles. With this in mind, it can sometimes be difficult for family members to travel to Bangor to discuss care options and be with their loved one, let alone travel out of state for more extensive treatment.

"That's a huge issue if all their family and loved ones live in Presque Isle," Miller says.

For some residents of Maine, just getting to Eastern Maine Medical Center, which serves two-thirds of the state, can be as challenging and complicated as going out of state for healthcare.

"The family is an important resource for staff who want to know what is best for a patient who cannot speak for him or herself, but it can be difficult to have a family meeting when family members live hours away and can't get to the hospital," Miller says. "People aren't just a subway ride away."

Getting family input requires creativity on the part of the whole patient care team, including nurses, social workers, physicians and others, she says.

Ethical conflicts also can arise when patients and caregivers have more than a patient-doctor relationship. Small towns are a lot like the bar on Cheers; everybody knows your name — and your parents, your children, what kind of car you drive, where you went to eat last night.

"A lot of times, patients and caregivers are related to each other on more than that level," Miller says. "That's one set of ethical issues that really arises quite a bit."

By providing caregivers with the tools to come up with ethical options for patients and families to consider, Miller says she's hopeful that such discussions become part of the healthcare dialogue.

"Bioethics in a rural setting presents many challenges due to limited economic resources, reduced health status, an aging population, problematic access to care and caregiver stress," Miller says. "There are no easy answers, but a team approach that emphasizes listening, deliberation and core ethical values in crafting a plan of care that best meets the patients' needs goes a long way toward improved health outcomes."

by Aimee Doloff
January - February, 2009

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