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You can't get rid of the old ones: health care, the aged and the dying.

UNIDENTIFIED: Dad's dead. Mother's dead. Sister died - too many Bex powders. My brother Jack is dead. He used to drive for Tooheys. He fell off a truck and got killed. Harry is alive. He's next to me. Florrie is alive. She's got two children. She lives down in Young Street, Annandale. I'm alive. I'm the oldest - 75. You can't get rid of the old ones.

LIZ JACKSON: You can't get rid of the old ones, eh. Well, in the United States, they've come up with a pretty chilling technique for doing precisely that. They call it `granny dumping'. The escalating cost of medical care for the aged, has led families to literally dump their elderly relatives in the parking lots of public hospitals and drive away. Here in Australia, we're not so brutal, but we do face some of the same problems: an ageing population and a health care system skewed to high-tech, high-cost care for them. Should we be re-thinking our priorities? This report by Kathy Gollan.

KATHY GOLLAN: Our late 20th century medical system has one great problem - it's the way people keep getting old and then dying. From birth to late middle age, nothing is too much trouble. You can get born too early, break a leg, chop off a finger, clog up your heart valves, and you can expect a great service. But should you then repay all that trouble by getting a boring, incurable disease of ageing like arthritis or dementia or diabetes, then the medical system doesn't know what to do with you. It's the very successes of medicine that have created our difficulties. Here's Daniel Callahan. He's Director of the Hastings Centre of Medical Ethics.

DANIEL CALLAHAN: Say, 150 years ago, people tended to die of infectious disease or plagues: smallpox, bubonic plague, typhoid, typhus, diphtheria - a whole range of things which, however devastating, had the one advantage that they killed you pretty quickly, or, if you recovered, you recovered pretty quickly. The difference now is that having really had a terrific and wonderful success against those infectious diseases, we're now left with what I think are the really tough ones: heart disease, cancer, stroke, Alzheimer's disease, diabetes - conditions that are chronic, that are very difficult to cure totally in any fashion, conditions where all that medicine can really do is sort of comfort patients and provide ongoing care during their acute crisis, but medicine can't cure them, and, perhaps, will never be able to cure them.

So, you have a very great difference there, and it's the difference that helps explain cost, because it's very expensive struggling up against this sort of frontier of ageing. But you also, I think, get some of the profound dilemmas we now have about caring for dying patients. Many elderly people don't want aggressive high-technology care, but many of those same old people who don't want it, are going to get it.

JOHN DEEBLE: I remember a quote from an American doctor who said that there are many patients who are so sick that nothing much can be done for them, but nobody is so sick as more tests can't be performed; and in many ways, a doctor wants to do something for his terminally ill patients. He feels he must do something. He will try to do any investigation that seems to offer something, and it's as much for his satisfaction as it is for the patient.

KATHY GOLLAN: Do you think it's a way for the doctor almost to distance himself or herself from what's happening?

JOHN DEEBLE: It's a way for the doctor to feel that something is being done for the patient, even though in practice the results are not going to contribute much to treatment.

KATHY GOLLAN: That's Dr John Deeble who's author of `Directions for Pathology'. So, in Australia, too, there's that same conflict for doctors whose training and technology leads them to try to maintain life at any cost. Dr Dalarus(?) Russell, who is the medical director of a small public hospice, comes across this often.

DALARUS RUSSELL: We have a little problem sometimes with the community nurse consultants, and they voice their despair that Dr X just won't give over. And I've had discussions with doctors and I have rung doctors up and said `I'm ringing to tell you that your patient died last night', and there's a shock silence - `Died? - but the operation went very well'. `Well, yes, you're right, it did go very well, indeed. But of course, it probably had something to do with the fact that, you know, her liver was full of secondaries at the time'. Now, some doctors .. in my experience with the dying, over the last 12 years, some doctors are devastated that a dying person actually dies.

KATHY GOLLAN: I asked Dr John McCallum - he's from the Centre of Epidemiology and Population Research in Canberra - whether there were cases of geriatric patients having inappropriate high-technology operations.

JOHN McCALLUM: I know that it can be done. With the location of a lot of geriatric assessment expertise in hospitals, I think there's been a better system operating for those kinds of decisions, but there are still no guidelines for doctors on some of those things. So, providing coronary bypass surgery for a 95 year old may not be a good idea for very many reasons, in terms of the cost and the exclusion of other people from a scarce service, but I don't think there are any ethical guidelines on that in Australia. I know the US guidelines are rather strict on this. They say that if a procedure is available, then it should be provided. Now this, of course, is an apparently easy solution, but when you get to a situation where some other people don't get the service, where there's not enough services to go around for all the people who need them, that really isn't much of a help.

DANIEL CALLAHAN: What's happened, though, I think is that we've sort of brought modern technology into close relationship with the principles of the sanctity of life, so they sort of play off on each other. If someone is dying, we feel, `My gosh, progress means that we should try as hard as we can to keep them alive', and if progress won't do the job, then we can always invoke the sanctity of life and say `My gosh, it's better to be alive than dead'. I think we end up getting a rather strange combination of a kind of a view of the value of life that's too heavily dependent upon technology to give it this value any real bite. On the other hand, when technology fails, we often use the respect we owe life as a kind of excuse to keep going. Doctors, of course, find it very difficult to stop treatment. They're not trained to stop treatment. They're trained, on the contrary, to go forward with treatment. They don't like to talk with patients about dying. They prefer, if at all possible, to .. I think they don't always like this in themselves, but I think they find it easier to work with the machines and the powerful technologies than to actually sit by a bedside and engage in an extended conversation with the patient.

KATHY GOLLAN: Daniel Callahan. One person for whom these contradictions came into tragic focus, is Mr Crothers of Scone. His wife was in the last stages of cancer when she was moved from her local hospital to the city. She only lasted a week in the city, but during that time, she was bundled into an ambulance and moved to a third hospital.

MR CROTHERS: It was a funny thing, really, because when .. not funny at all, but when they took her out to Calvary Hospital, even then they said `Oh, you know, we get a lot of cases like this one. They come in and they're pretty crook and they stop here for a week or so, and then they go home again'. I said, `Oh yes, that's great' because, you know .. but nobody actually said that this is it, and obviously they knew.

KATHY GOLLAN: Did the doctors give you or your wife any choice about the tests that they were doing on her?

MR CROTHERS: No. No, they just seemed to shove needles in all the time. As I said, she was black and blue. But I tried to get in, you know, and they did want to do .. I think it's called a myelogram - something to do with the spine, but decided against that. No, they sort of took over. Well, I mean, you know, I'm not a qualified person, so you only assume that what they're doing is right and proper thing. But, you know, in hindsight, I think probably most of it wasn't necessary, if any of it, really.

KATHY GOLLAN: It's not only dying that people can fall foul of medical priorities. Geriatric medicine is the ugly duckling of the medical degree. Undergraduates spend only two weeks on geriatric issues, and the universities have shown a marked reluctance to set up chairs in geriatric medicine. As a result, the research into physiology of the ageing body isn't being done. We do know that drugs affect older people differently from the younger population. Professor Robert Helm who fills the non-university funded chair of gerontology at the University of Melbourne.

ROBERT HELME: Older people certainly are at risk of side-effects from medication. The average person over the age of 80 is going to have somewhere between three and four active diseases for which they are on medication, and those medications may interact with one another, they may well have potent side-effects. The other major feature is that older people have organ systems which are working well enough, but which can break down under stress. They're working near the limit of their reserve. This means that their liver, although it's capable of breaking down medical products quite reasonably, if there's a slight excess of medicine or there's some further damage through disease to the liver, then they're clearly at risk. And the same thing, of course, applies to their kidneys where a lot of drugs are excreted, or, indeed, to the target organs, such as the brain or the heart, at which site these medicines are working. So for all these reasons, yes, older people are at risk.

KATHY GOLLAN: Do you think one of the problems might be that most drugs are tested on a younger population, too?

ROBERT HELME: That's a very real problem. It's one of the things that makes me quite annoyed that the drug companies, for reasons which are quite clear, wish to undertake drug trials in young people with only single disease states. The problem, of course, is that those drugs then get used in old people who have multiple disease states; so, it would be much better if they tested their products at least in some older people.

KATHY GOLLAN: It's alarming to realise that the average person over 70 takes nearly six different medications a day, and according to one recent study, up to 25 per cent of acute geriatric admissions to hospital are the result of adverse drug reactions. Silvia Marcelo runs health education groups for older people.

SILVIA MARCELO: People might be on pain killers, for example. As a general rule, pain killers for minor aches and pains, or they might have some problems sleeping, so they'll be on mild tranquillisers. They might have some problem with mobility and, therefore, they might get some anti-inflammatory drugs for their arthritis or they might have some problems with their stomach, their digestion, so they will be on antacids, or they might have some problem with their respiratory tract, or they might have a touch of asthma or some bronchitis, chronic bronchitis and, therefore, they'll be on extra medication on that. They might be on fluid tablets for their blood pressure. These are the main ones, but also I think that the problem gets compounded because people will also get on non-prescribed drugs. They go to the chemist and they might have some extra drugs on that regimen, and because they're not prescribed at the doctors, they're not seen as drugs proper, and people don't think that they might interact with another one that the doctor has prescribed.

KATHY GOLLAN: The fact that the average number of daily medications amongst older people is nearly six, does that say anything to you, other than the fact that old people have a lot of things wrong with them?

JOHN McCALLUM: Yes, it says that there's a real lack of co-ordination in the kinds of services that are being offered to older people. Many of these drugs interact with one another to produce even worse states of health. Some of them produce conditions near confusion which causes some older people to be mis-diagnosed as demented when it's only the pills they're on. That whole area, I think, is one that where the priorities in the pharmaceutical and in the health services system really do not work very well for older people.

KATHY GOLLAN: What are these priorities?

JOHN McCALLUM: Well, that if you find a disease, you go in to a specialist who has that disease, and we've seen dramatic increases in the provision of specialist services to older people through the 1970s and 1980s, in Australia. So, you identify that disease; you go to a specialist; and then you get a lot of pills. Now the problem is, if you're an older person, you have a number of those diseases, and the specialists are not at all talking to one another, and you're going to get prescribed medications that are potentially quite harmful when they're put together.

UNIDENTIFIED: Well, I had a triple bypass eight years ago. I've coped very well with it, other than it's left me with chlordication, which is a vascular problem in the legs, and I can't walk. I've got high blood pressure and I'm on a tonne of tablets daily, some of them four times a day, but I've coped quite well. But for this chlordication, they have now given me some tablets, Trentle-40(?), which will cost me $81 a time. I can't get anything back on them, of course, and, you know, just got to grin and bear it.

KATHY GOLLAN: So how many drugs would that add up to a day that you're taking?

UNIDENTIFIED: Two for blood pressure and heart - they sort of go together; two fluid tablets - I take those three times a day; one for the chlordication - that's the new one, that is the new one. Oh well, vitamins, I mean, I take those of my own accord.

KATHY GOLLAN: A study was conducted by the Australian Pensioners' and Superannuants' Federation to look at the needs of older people with chronic conditions. They talked to 142 pensioners with arthritis or diabetes about their doctors and their medication. Linda Adamson conducted the study.

LINDA ADAMSON: Looking at a group of people that are on average about five medications, we were speaking with people that were on 22, 28 concurrent medications. Now, you can imagine, it's very hard to determine exactly what the impact would be. Other than that, all medications have adverse reactions, and it's unknown what the interactions between those medications are on the older body.

KATHY GOLLAN: So, the person who's on 22 or even 10 medications, what symptoms are they experiencing?

LINDA ADAMSON: Well, if you look at a class of drugs like benzodiazepenes - the minor tranquillisers, common medications like Valium, Mogadons, Serepax, and we've spoken with older people that have been on those medications that have suffered from confusion, dizziness, they're falling over, they end up in hospitals because they've got a fracture. Now, we're not saying `Go back to your doctor. Take yourself off these medications'. We're saying there has to be a balance and there has to be involved consumer-doctor discussion about the benefits and the costs of those medications.

UNIDENTIFIED: There was one lady and she just regularly takes a sleeping tablet, one or two every night, and she said she's done it for years. And like I said `Oh, but don't you think you could do without them now?'. And she said, `No'. She said `I know I can't'. And she was adamant about, you know, just taking these sleeping tablets every night. And there was another woman I heard of - she was put in hospital. They didn't know what was wrong with her, and she was on a lot of medication. She was actually taking about 11 tablets, and when the day she was put in hospital, the Sister came around and said to her, `Well, give me your tablets and I'll put them out so you'll be able to take them', and she said `They're all in that bottle over there', and when the Sister went over, all the 11 tablets were in the one bottle. And she said `How do you know what to take and when?', and she said `I take them all together, so I won't forget', and of course, that's what was making her sick. Like the doctor had prescribed them over a long period of sickness, like arthritis, and I think she had high blood pressure, but, in all, she had to take 11 tablets every day.

ROBERT HELME: Of course, there's a lot of patient pressure on doctors to use medicines. It's very difficult to wean somebody away from their sleeping tablets, even though you know quite well that in the literature it's proven that after being on them for a few weeks, they are not going to be of benefit. When you try and take them away, there will be withdrawal symptoms if it's not done slowly and carefully and with a lot of explanation. And you get to a situation where the patient is demanding that their medicine be continued.

LINDA ADAMSON: But they do have particular needs of the health system, and they do have particular expectations, I think. We're talking about a generation that have lived through the 1950s, 1960s, when there was a virtual explosion in the medical science field, medical technology, and most importantly, an explosion in pharmaceuticals. So, they're a generation that have lived through a time when we were looking to medications to be the magic bullet, the cure for all conditions, and doctors as being able to provide instantaneous treatments and cures. So, I think it has coloured their expectation of the health system. It has particularly coloured the way that they relate to their medicos.

KATHY GOLLAN: So how do you feel when you go to your doctor?

UNIDENTIFIED: Well, I find he's all right. I don't feel comfortable with him, really. I don't know .. no, I can't tell you why, but I seem to have to pump him all the time. I mean, he will sit and talk, but I mean, as I say, you've got to pump him for everything you want. Now, I just felt that my blood pressure .. he said one day, my blood pressure was fairly low for me, and I said `Well, will I cut one of the tablets .. one of the blockadrin(?) down?', and he said `Oh, oh, yes', you know. Well, to me, that just wasn't satisfactory enough. I would have liked him to have said `Well, I think we will', you know, `and give it a trial'. I just felt that he just wasn't definite, you know, with the decisions. He should have been the decision-maker, not me.

UNIDENTIFIED: Well, I've just finished a triple bypass. They were absolutely wonderful. Wonderful. Absolutely wonderful. I didn't even have to think. They thought for you. And I've been wonderful ever since.

KATHY GOLLAN: So how many different medications are you on?

UNIDENTIFIED: I'm only on two for the heart and one for me nerves - supposed to be for me nerves - but I was better off without it. It makes me feel sick sometimes, and sometimes I forget it deliberately. I have glaucoma which they cannot do anything for. They can do it for everything else, but they can't touch glaucoma.

KATHY GOLLAN: Did your doctor recommend you to anything like the Blind Society or anything else?

UNIDENTIFIED: No, the doctor had nothing to do with it, love. Someone else told me about it, this Blind Aid Society. And they're coming this week to see if they can improve anything for me, such as phone numbers. They'll make them larger, if you want them. And I have to have a white stick.

KATHY GOLLAN: As our life span continues to increase, so does our level of sickness. We have, in fact, traded in death for a few extra years of disability. One in three people over 70 now reports a significant disability. There have been some major surgical successes. There's cataract surgery and hip replacement and coronary bypass, but there's not much interest, as yet, in some of the other disabling conditions. Dr John McCallum.

JOHN McCALLUM: The highest prevalence thing is arthritis and rheumatism. Cardiovascular conditions are also a major cause of disability, and the third big one is respiratory conditions. So, they're the big three that tend to produce disability, and of those, the interesting one, I think, is the arthritis and rheumatism, and sight and hearing loss are other major things that cause disability and cause tremendous upset and unhappiness in older life, and we really don't have a kind of major effort in those areas.

KATHY GOLLAN: Well, why is that? Why isn't there the research into those more general things that don't kill us, that really sort of overwhelm people in the last years of their life. I mean, is it something to do with the sort of rule of rescue instinct that people are only interested in what's going to kill them, that is, the heart disease or the respiratory problems?

JOHN McCALLUM: Well, it gets us right to the priorities of the medical and hospital system we work in. The priorities have developed over this century with a very tight focus on disease and pathology, and, in particular, on those diseases which kill. This is an entirely appropriate focus if we're talking about younger people where preventing an early death is a major advance and a major help. It is not necessarily the most appropriate focus when we come to talking about older people, talking about very marginal gains in actual life years. And when we're talking about the wishes of people themselves, which are largely about being able to be independent and to be able to manage by themselves, not being a burden on other people, and that, of course, gets us to the point of disability, and that that really is where the focus should be and it hasn't been the focus of the hospital and medical system over the last 50 or so years.

KATHY GOLLAN: In Linda Adamson's study of chronic sufferers, those that were the happiest with their condition, were those who'd been able to tap into home support services and community health care. Through councils, charities, State and Federal government programs, they had access to home nursing, cleaning, stress reduction classes, hydrotherapy, counselling and palliative care. These services were vital to them, but they were overextended and unco-ordinated, and there was always pressure on the clients to make way for others on the waiting lists.

LINDA ADAMSON: To be a consumer with a chronic condition, one needs an awful lot of perseverance, verve and good humour to find out simple things like a straightforward diagnosis, to find the links between your GP, your specialist, hospital, auxiliary care, community care. When we were doing work with people with chronic conditions, the ones that were happiest with the health system were those that had access to multi-disciplinary clinics, for example, diabetes clinics. In that case, they had access to medicos - doctors. Alongside that, they had access to dietitians, physiotherapist. They had access to a range of health professionals. That really helped them cope with their disease, not just the medical aspects of the disease, but the psychological and the social aspects as well.

DALARUS RUSSELL: In some parts there is under-provision of these vital services, particularly in terminal cancer where the desire of everybody concerned is to keep the patient at home, and there is not enough of these very vital women, the generalist community nurses and the clinical nurse consultants in oncology who assist the general practitioner, assuming he lets them, to maintain the patient at home when that patient and the family want them to be at home. There is under provision of this. And I know from dealing with these women, what large case loads they bear and how great the demands on them are.

KATHY GOLLAN: What are the case loads?

DALARUS RUSSELL: Well, a friend of mine has 120 on her books; that's one woman. I know somebody else who only has about 40. I do feel 120 is a little excessive.

KATHY GOLLAN: Dr Dalarus Russell. And now, Dr John McCallum.

JOHN McCALLUM: We've seen through the 1980s, major changes in how health services get delivered to frail older people - this is with the process of geriatric assessment and services delivered to the home through home and community care. And the way those have come in is really to bypass to a large extent the medical profession; so that's excluding the geriatricians who've been involved in this. Those changes have come in really bypassing general practitioners in the community who to some extent oppose these changes of delivering services that help people to maintain their function, rather than dealing with specific diseases where it's quite commonly reported by people working, providing home services, that GPs say things like `Nobody ever died from a dirty home', so they're not interested in being a part of that service system because it doesn't deal with obvious disease and illness, and they don't really see the purpose of that kind of service. Now, a very dirty home for an older person indicates that they are not functioning normally and that that may well be something that affects their dignity and certainly their social acceptability; so that's a very important thing.

SILVIA MARCELO: What we find is there's an incredible non-awareness on the side of the doctors, even though the ones that we like to refer because it's easier for them, but there is a lack of awareness that there are services outside there and every area does have an incredible network of services that are already there. I'm thinking of, apart from all their home and community services that are there and the doctor ought to know that they are, but also support groups that are around, organisations that reduce isolation for somebody is one of the big problems with the elderly because it compounds the wrong use of medications - all those services are out there but there isn't much response from the doctors in terms of referring.

KATHY GOLLAN: Silvia Marcelo. Every health policy change has at its heart the debate between advocates of community and home-based care which is cheap but publicly funded, and those who'd like to give more rein to hospital-based care, with the possibility of moving some of those costs into the private sector.

LINDA ADAMSON: To many older people, the health debate seems very, very lopsided. There's far too much attention being given to the acute end of the spectrum, to intervening in life-threatening conditions, and not enough attention and not enough debate and not enough discussion in the health system about what is happening to people that are living with chronic pain. Do we want to put resources into heroic interventions, into saving very, very young babies, into more heart surgery - do we want that? Or do we want to, say, provide more pain pumps for people that are living with chronic conditions, pain pumps that would enable them to continue functioning and to control their own medication use in the community in a humane way and in a way that enables them to live as independently as possible and with as much dignity as possible?

KATHY GOLLAN: Linda Adamson. At least the debate still goes on here. In the United States, it's never existed. Over there, private medicine funded by employer-based insurance schemes, has long since captured the high ground. Public medicine is provided only for the very poor and the very old - if you're poor enough. Peter Botsman of the Evatt Foundation has just returned from a year's study of the United States system.

Well, say, for example, you were an 80 year-old widow in good but failing health, hadn't worked much, so didn't have medical insurance from that sort of point of view, but was reasonably well off. How would you go for getting suitable care for your needs?

PETER BOTSMAN: Well, the first thing you'd probably have to do is sell off all of your available assets and try to disperse them to your immediate family and in a surreptitious manner, and show that you had zero income and zero assets, because that way you would qualify for the government health insurance scheme, which is called Medicare.

KATHY GOLLAN: And what sort of home care would there be - Meals-on-Wheels, home nursing, community nursing, that sort of thing?

PETER BOTSMAN: Well, it depends whether you're living in a walled city or not. A walled city is a metaphor for what's happened to the American society after Reagan and Bush. Basically, people who live in walled cities have the very best of everything. They have their own police forces, they have their own security agents, they have their own community care, and they live relatively well. But if you live outside a walled city, then chances are you're going to have a very, very hard time getting any kind of home care, any kind of in-house care, which means that you will go, once you start to deteriorate, into an emergency ward of a hospital. And this is where we get into some of the phenomenas of what are so-called `granny dumping', where ordinary families just can't afford to support their aged relatives, and dump them at an emergency ward of a hospital, with just a suitcase full of their belongings.

KATHY GOLLAN: So what exactly happens? Does a car drive up, screech of brakes, an old person falls out, the suitcase is thrown after them, and the car disappears in a cloud of dust, never to be seen again? Does that really happen?

PETER BOTSMAN: It happens. I mean, the thing is that we .. these are the sorts of spectacular images of America that we love to dwell on. It does happen. It's a very large country of over 250 million people. It happens though, and it happens not because people are uncaring about their relatives, but because at the moment in the United States, medical bills are so horrendous that a family just cannot support an aged person if they start to get sick, and it's probably better off for the aged person and the family concerned that they go into a public hospital where they may have a bed in a hospital, no matter how inappropriate we may see this care as being, they may be better off being recognised as a public case than to stay in the family household and just deteriorate there without any help at all.

KATHY GOLLAN: So would that mean that the relatives couldn't go and visit that person, because otherwise they'd be landed with the bills?

PETER BOTSMAN: If there is any tracing of the relatives of the person that was granny dumped, yes, they would be hit with the bills and that would probably mean they would go bankrupt in all but the most rich and middle class families, with something like this. I mean, $100,000 health bill is not an uncommon thing in the United States, at the moment.

KATHY GOLLAN: What are the aspects that are so expensive that are being provided?

PETER BOTSMAN: Well, I find it quite amazing that while I was over in America, we were talking about over-servicing in Australia, and what we were talking about were over-servicing of many cases, aged people by general practitioners, giving them too many pills, those sorts of things. Now, that's a very serious problem for us, and I recognise that it is, but we have 70 per cent of our medical profession are GPs that are to do with general practice and 30 per cent are specialists. In the United States, they have 30 per cent general practitioners, 70 per cent specialists. So when you go to the hospital, if you're an aged person, or if you go to a doctor, you'll be referred to some kind of specialist who's been trained to identify a particular kind of symptom or a particular kind of affliction you may have, and he is likely or she is likely to treat you for that affliction. So, you what you get is an over-servicing problem magnified by 100 compared with what we have, and you have aged people who need companionship, that need better home care, turning up spending a lot of time in a hospital with high-tech facilities all around them, perhaps which they don't need, perhaps which have been badly diagnosed, and so on.

KATHY GOLLAN: Peter Botsman. Faced with an expensive and inefficient and unfair health system, Daniel Calahan, who's Director of the Hastings Centre in New York, has come up with a radical proposal which has caused much heartache in the United States. He proposes to ration health care to the elderly. I asked him how it would work.

DANIEL CALLAHAN: Well, essentially, the way I would see things work here, I've thought primarily of our government provided health care for the elderly that it would simply be declared that beyond, say, the age of 80 or 82, whatever we might politically debate as a cut-off age, that certain forms of very expensive technology simply would not be available. This isn't to say that the elderly would be denied them, what they would be denied would be payment for them. If they want to save money in order to buy the expensive technology past the age of 80, say, that would be fine, but, beyond that, the government would in fact say `Look, we're going to give you a decent life span, we're going to help you try to avoid premature death, we're going to help you go from being a young person to becoming an old person, but we can't promise an indefinite sort of open-ended level of care, particularly the kind of care that gets very tightly bound up with expensive medical progress'. So, the government, in effect, then would say `Look, you might .. beyond a certain age, your government will no longer pay for dialysis, it would no longer pay for an extended stay in intensive care unit, it might not pay for certain forms of heart surgery'.

The government, in short, would simply have a list of things that would not be covered. At the same time, I would stress I don't want to abandon the elderly. I think it would be important that there be good long-term care for the elderly, home care really for pain, sort of basic medicine should be available. My target is really the more expensive kinds of procedures and particularly the phenomenon of using these more expensive procedures on an older and older age group. That's why I think, essentially, we'll have to use age as the limit.

KATHY GOLLAN: Do you see us progressing any way down the path that the Americans have gone along, as Medicare comes under attack and as private medicine becomes more valued, the same sort of skewing of values towards high-tech, high quality care just for a very few?

PETER BOTSMAN: I am amazed that everybody outside of Australia recognises that we have, with all its faults, a great health system, both for ordinary people and for the aged. We have a lot of .. I'm not complacent about this, there's a lot of things that we need to improve, but people outside Australia recognise what a wonderful achievement Medicare was, and I think many people will come to Australia over the next few years to see the shape of our aged care programs as they develop over the next 10 years. To have universal health insurance cover for all Australians and to be only spending 8 per cent of our GDP on our health system is an extraordinary achievement. And the problem I think is that it's like anything that you don't value properly, if you don't value something, then you will lose it. And one of the most distressing things for me is to look at the Opposition Fightback package on health care and see that that is, in fact, a move towards the American system. Our system, at the moment, is skewing away from hospital-based intensive care, towards more community care, independent living type of appropriate health care for the aged.

In the United States, their system with its combination of private doctors, private specialist doctors, private medical health insurance and most hospital based care is that aged care is skewed towards inappropriate medical high-tech care. Now, if we go that way, that's what will happen to us. We will start to revalue the kind of strategies that are now being put in place and more people will end up in private hospitals and we will start to have a track between the nursing home and the private hospital - private or public hospital based care, and there'll be no track from those places to your own home or to appropriate aged care and a kind of area combination of services which would include social workers, people who can make your house better to live in, Meals-on-Wheels, appropriate medical advice about nutrition and other issues like that, as well as top-of-the line health care, hospital care, if you need it. But our system, hospital care is something which is a last resort. In America, it's a first resort.

UNIDENTIFIED: Getting older. I was born in 1900. I'm in my 78th year now. I wouldn't have much longer to go. I just take it as it comes. I feel quite happy about the whole thing. When I was 25, I was a bit of harum-scarum. I've settled down a lot. I feel more contended now than I've ever felt in my life. I've only got a certain time to go, and I just take things calmer and just leave it go.

KATHY GOLLAN: What would you, as somebody who's studied old age, how would you like your old age and your death to be?

JOHN McCALLUM: I'd like my death to be quick. I'd like my old age to be relatively active. I'd like it to be one in which my social networks were still operating so there were people I could talk to, there were people who could give me emotional support, people who I could talk to about the changes that were occurring with age and with disease in myself and my body. But I wouldn't like to suffer severe dementia and to know that I was, if you like, suffering two deaths, one, first of all a mental death, and then a physical death. And I wouldn't like to spend a long time in pain or in suffering. So, I think that's a fairly normal desire to live a long but successful life, and to die relatively quickly.

LIZ JACKSON: `You can't get rid of the old ones' was produced by Kathy Gollan; production assistance, Linda McGinness; technical production, Judy Rapply. Thanks to the women at the Bondi Junction Legacy Group; and the poems, by the way, were taken from a collection written by the residents of Sydney's nursing homes.