End of Life Issues among the Elderly: Emerging Role of the Medical Social Workers

The issue of end of life among the elderly is understudied by researchers and practitioners especially medical social workers. The end-of-life period is a period of when the body systems are shutting down and death is imminent, typically lasts from a matter of days to a couple of weeks among the elderly. The paper explored the emerging issue in caring for the elderly at the end of life stage. The paper x-rayed the emerging roles of the medical social workers. The paper recommends that, developing capacity of individuals (informal caregivers) networks will bridges the gap in absence of the primary caregiver to provision of comprehensive care planning for the elderly at the end of life stage.


Introduction
Death is a natural stage in the cycle of human life as well as in an 'aging society' . In Africa, the care of older person ages 60 years and above is gradually becoming a continent priority [1]. The face of Africa is changing like every other region in the World, the population is ageing in Africa this is much more quickly [2].
A comedian Woody Allen is said to have remarked on his 40th birthday, 'I shall gain immortality not through my work but by not dying' (Quoted in Times, 2011).
A lot of the elderly echo this desire to live forever, but life inevitably ends in death. Death and dying are inevitable events in a human's life. Although no one can escape this experience, death rarely receives attention from scientists and society as a whole. By 2020, 2.5 million of the elderly persons will die annually in the Sub-Saharan African [3]. Advanced technology and modern medicine have increased the length of life; however, quality of life (QOL) at the end of life remains relatively unexplored due to the poor socioeconomic condition of the senior citizens.
In the African region there has been an increasing awareness of the inadequacy of end of life care and of the poor knowledge of patients' wishes about their medical treatment at a time when they lose the capacity to make decisions resulting in patients being cared for in a way they would not have chosen. Old age can be emotionally healthy and satisfying time of life and can also be characterised by physical and mental impairment [4]. There isn't a single specific point in an illness when end-of-life care begins; it much depends on the perception of individual [5].
The end-of-life period is a period of when the body systems are shutting down and death is imminent, typically lasts from a matter of days to a couple of weeks. Some patients die gently and tranquilly, while others seem to fight the inevitable [6]. However, in the end of life stages of many terminal illnesses, care priorities tend to shift, instead of on-going curative measures, the focus often changes to palliative care for the relief of pain, symptoms, and emotional stress [7].
Life and death are familiar and equally acceptable part of what self means [8]. Death is characteristically seen as a welcome relief, or as Japanese ancestors' worship, a step upward in social mobility to join the revered ancestors [9]. In Buddhism, death is merely a passage to another reincarnation unless the person achieves an enlightenment that releases him or her from the eternal cycle [10].
The symptoms at the end of life stage vary from elderly patient and according to their life-limiting illness, there are some common symptoms experienced at this stage where the caregiver is expected to provide comfort for the dying elderly ones. It is important to remember, though, that experiencing any of these symptoms does not necessarily indicate that the patient's condition is deteriorating or that death is close [11].
Older people play a vital role in African society of today. Across the continent, millions of families would not survive without the contribution of older people from caring for orphaned grandchildren to providing much-needed household income. Yet, older people are often excluded from development programmes and discriminated against in quality care and social support to aid peaceful exit. Despite the indispensable contributions of older people in Africa to the economic, political and religious growth of this people.
In the Nigeria there are still experience deepening poverty, discrimination, violence and abuse, as a result, care at the point of end of life are either inadequate or non-existence [12]. With advances in Life support, the line between who is alive and who is dead has become thinned. In the rural areas, for example, older persons who are dying are deprived of the needed care in four [4] areas-Physical, comfort, mental and emotional needs, spiritual needs and practical care tasks.
Hence, people die the way they live so, the inner journey is always full of; fear, depression, guilt, hope, denial and anger because of poor psycho-social support needed for peaceful exit. However, elderly who dies of chronic illness neither palliative nor geriatric services are wellequipped to care for dying older people. Hence holistic care is the responsibility of all health care professionals but it has been neglected.

Emerging roles of medical social worker in the care of elderly at the end of life
According to the national association of social workers (NASW), (2010) medical social workers working with the elderly at the end of life is interesting and often rewarding because it is a cooperative venture with other geriatric professionals. Medical Social workers help individuals and families deal with their problems by providing therapy, making referrals to other services and engaging in more general social planning for the elderly at the end of life.
The elderly patient can loose control over their feelings, social interaction, ability to concentrate and the future are all threatened or lost in the illness which could lead to depression and feelings of helplessness which may, in turn, aggravate the physical condition. The medical social worker offsets the feelings to make patient feel like informed participants in their own care. The medical social worker help a patient understand illness more fully and deal with their emotions and response to illness, such as depression or anxiety, through psychotherapy.
Medical social workers organizes family therapy for dying patient. The medical social worker uses family therapy to ameliorate difficulties in the family settings, maintaining their resources and perform their daily activities. The task of the medical social worker during family therapy with the families of the elderly patient is to deal with communication issues.
Medical social worker addresses the difficulties in communication which are tied specifically to the dying process because elderly patients may feel guilty tying up the finances, time, and emotional energies of the family, yet may not know how to express these concerns. The medical social worker ensure that everyone can communicate mutual love and respect as a result patient can see the beneficial effects he or she has had on others, gain a sense of the importance of his or her existence, and come to terms with the fact that he is leaving the family and knowing much benefit will be left behind.
One of the important roles of medical social workers in the care of the elderly patient who is at the end of life stage is the provision of more humanized environment for them and their family. The social worker helps in providing hospice care or interdisciplinary care to dying persons and their family.
The paper recommends that, developing capacity of individuals (informal caregivers) networks will bridges the gap in absence of the primary caregiver to provision of comprehensive care planning for the elderly at the end of life stage. Care of the elderly should move from the patient-centred approach to the whole-system approach that encompasses the patient's interpersonal and family relations as well as the best of both medical and social care, in order to optimize their quality of life.