Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Restraint, covert treatment and autonomy
- Peter Allmark (16 March 2001)
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Evidence of ageism in Parkinson's disease management by GPs
- Douglas MacMahon (17 March 2001)
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Care of older people: getting the attention that they deserve
- Chau Tran (17 March 2001)
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Dignified Medical Care for Seniors
- I Dan Dattani (26 March 2001)
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Growing Older With Dignity
- Sam Ramaiah (27 March 2001)
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Elder Abuse : A Community and Health Care Issue
- Phillip Malouf, Felik Paulus (19 April 2001)
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Dignity and autonomy in older people- wrong diagnosis, wrong treatment
- A J D Macdonald (24 April 2001)
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Peter Allmark, Nursing lecturer University of Sheffield
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Lothian and Philp successfully convey some of the ways in which negative attitudes toward the elderly undermine their dignity and autonomy. Two practices that seem reasonably common in the treatment of the elderly are particularly undermining of autonomy and may be worthy of further empirical study. The first of these is restraint. This need not take particularly dramatic forms. Frail people who have tables slotted through their chair legs can, effectively, be restrained. The second is the covert administration of medicine in food and drink. There may be occasions when both practices are justified in the patient's best interest. However, what is worrying is that the practices may be driven by the "pessimistic" attitudes Lothian and Philp refer to. Even more worrying is that they may be driven by shortage of resources. This last issue is one that would also need to be addressed in any attempt to enhance dignity and autonomy in the elderly. |
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Douglas MacMahon, Consultant Physician Camborne-Redruth Hospital, Cornwall
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This excellent article1 reviews the evidence of institutional ageism that will unfortunately be familiar to many geriatricians, and many patients and their families. There is little research of its prevalence, and the authors refer to a number of institutions in which it is found. There is also evidence in the attitudes amongst branches of our own profession. I have recently been privileged to share some research carried out amongst British General Practitioners to investigate their attitudes to patients with Parkinson's disease - a common disease in the older person. The results of the survey2 clearly demonstrate that over half of GPs are not following best practice in managing new patients with PD (according to primary-care guidelines developed by the PDS Primary Care Task Force3) with elderly patients most likely to be affected. Both these Primary Care guidelines, and the complementary specialist ones4 advocate that all new patients should be referred to a specialist for the crucial stages of confirmation of diagnosis and initiation of treatment. Yet this research shows that only 45 per cent of GPs provide this option to all patients, while the remaining 55 per cent discriminate by age in their decision to do so. The research shows a clear relationship between patient age and the GPs decision to refer or treat: the older the patient, the less likely their GP will follow the guidelines and send them to a specialist, and the more likely the GP will start treatment, while awaiting or even without referral. This provides further evidence of ageism in the management of a common, disabling, yet eminently treatable disease. 1. Kate Lothian, Ian Philp. Maintaining the dignity and autonomy of older people in the healthcare setting BMJ 2001;322:668-70 2. The Parkinson's Disease GP Survey, Great Britain - conducted among approximately 400 randomly selected GPs throughout Great Britain. Conducted by Taylor Nelson Sofres PLC as part of their weekly Omnimed survey, 29 January - 23 February 2001. 3. Primary Care Task Force Parkinson's Aware in Primary Care. M Baker, D MacMahon et al. Parkinson's Disease Society, London 1999 4. Bhatia K, Brooks DJ, et al. Guidelines for the management of Parkinson's disease. Hospital Medicine 1998;59(6):469-480. |
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Chau Tran, PhD Candidate Institute for Clinical Evaluative Sciences, University of Toronto
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It is with great relief and satisfaction to see Lothian and Philp address an issue in a series of articles, that will become more pressing in the years to come as health care systems deal with the onslaught of the ageing population. The measure of a society is often done in terms of economics. We revere those that are healthy, productive and successful and pay less attention to those who are disabled or old. This is the distorted view to adopt as the true measure of a society is the respect that it pays to the elders. If it must be put in economic terms, then it can be argued that these individuals have contributed to the productivity of the society that they live in and righteously, deserve something fundamental, such as health care, in return. It is unfortunate that the elderly require advocates for their health care. The frustration that caregivers/family members have so commonly expressed in the need to be advocates in the first place is further evidence that training or appropriate selection of compassionate candidates to work with this patient population are required. This dissatisfaction has lead many families to take matters into their own hands and thus began the development of home care. But, another cycle then begins, that of caregiver burden. If any health care system had their act together in the first place, would these negative attitudes towards the elderly and frustration of caregivers be quelled? It is not known. In any case, the standards of care need to be raised but they also need to be measured. The performance of health care workers and institutions via quality indicators need to be measured on a regular basis to not only ensure that such standards of care are being fulfilled but that they are feasible. |
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I Dan Dattani, General Practitioner & Clinical Asst. Professor of Family Medicine(P/T Faculty)University Of Saskatc Acadia Medical Centre,3510-8th St East,Saskatoon.SK. Canada
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Yet again...another alarming report on the care of the elderly in the NHS. Having personally witnessed at first hand care of my father in one reputable NHS hospital, I can only voice my concerns at those who are ultimately responsible for his (their) care... the doctors under whom the patients are admitted. First and foremost, the word "old people" must be eliminated immediately in favour of a more respectful word "senior citizen or seniors". Second; in order to gurantee optimal and dignified medical care in the NHS, accountabilty must be introduced.Emphasis on evidence based medicine alone will generate neglect and hamper dignified care. What is needed urgently in NHS, are implementation of Clinical Practice Guidelines in a Hospital setting. This is the only way to ensure standardised and dignified care for all groups ( young vs 'older') and classes ( NHS vs 'private') of patients. Current standards of care in the NHS are highy variable and continuously being challenged by patients and their relatives as even reasonable medical care and expectations are often not met. |
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Sam Ramaiah, Director of Public Health Medicine Walsall Health Authority
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Dear Sir With the imminent arrival of the National Service Framework for the elderly, there will no doubt be ample debate about this large and growing but often neglected segment of our society. Increasingly, expensive technology and staffing shortages mean that health care providers are caught between resource constraints and the inevitable rising demand for health care. Issues to do with dignity and autonomy will be a recurrent theme, as in the paper by Lothian and Philip.1 Many older people are coping with chronic, often incurable illness. Managing daily responsibilities while coping with infirmity is difficult enough. Therefore, it is important that the elderly with their special needs are supported sympathetically. One other consideration in all this is the ethical and other dilemmas faced by professionals especially in the care of terminally ill people. As champions of the cause of senior citizens, it is important that we advance the sense of self that is so important at the late stages of life, particularly for those elderly patients with terminal diseases. The driving force behind health care for the aged ought to be centred on the specific needs of that individual. At the moment, however, we believe the care given is determined by the system. Patient advocacy can only work to the advantage of those for whom it has been instituted if sufficient consultation and dialogue occurs. Measures such as informed consent and choice are already in place, which go some way towards maintaining patients' independence. We need to move further forward however and preserve the patient's entitlement to independence. There is a pressing need to realign any new government policy with the needs of the chronically ill elderly. This ought to come with guarantees that the elderly will receive professional and support services within a health care system conducive to the individual's well being as a whole. In addition, extension of more services in the community: sheltered housing-type scenarios for example which keep patients independent are required. The aim of this type of service ought to be that older people are able to live out their lives as esteemed members of the social order and not an encumbrance to be carted off for institutional care. Yours sincerely DR BOLANLE AKINOSI
DR SAM RAMAIAH
Reference 1 Lothian K, Philp I. Care of older people: Maintaining the dignity and autonomy of older people in the healthcare setting. BMJ 2001; 322: 668- 670 |
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Phillip Malouf, Students Community Medicine,UNSW Macarthur Ambulatory Care Service,NSW,Australia, Felik Paulus
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Lothian and Philp(1) highlighted an important social issue in their article, which is that maintenance of an older person’s dignity and autonomy is essential in a health care setting. The authors pointed out how dignity and autonomy could be compromised by the insensitivity and disrespect of health care workers. However, the negative comments of older service users and their carers (as stated in the article) appear to indicate more than just insensitivity and disrespect. Some of these seem to border on the deprivation of an older individual’s autonomy and dignity; this would be more appropriately termed as elder abuse(2). It is reported that 3-5% of Australians over 65 years of age suffer elder abuse(2), figures that are similar to those in the United States(3). Only 1 in 14 cases are thought to be officially reported(4). The perpetrator is the victim’s spouse in more than half the reported occurrences, while an adult son or daughter is the abuser in 25% of cases(2). Elder abuse may be physical, psychological or financial and neglect is also a form of abuse(5). At this stage, few prevalence studies with carefully defined catchment populations are available in Australia(2). There is also a dearth of intervention studies for elder abuse(2). In addition, few guidelines have been provided to health care workers with regard to the management/reporting of suspected abuse. While health care workers are required by law to attend child protection programs, no such educational schemes existed for the protection of the elderly. With so little attention devoted to elder abuse, it is perhaps not surprising to find that many cases go unreported(6). Lothian and Philp(1) propose that a lack of education and training in hospitals predispose our elderly to this kind of abuse. The authors contended that “a key means of tackling poor attitudes by staff towards older people is through extensive and continued training”. The healthcare setting plays a vital role as a place of refuge for abused elderly people as well as an opportunity for health care workers to identify abuse before it progresses. However, focusing on abuse in a health care setting alone is too simplistic as elder abuse does occur outside of this setting. Wider community education is required as primary preventative measure. Public awareness programs outlining the prevalence and impact of elder abuse (similar to those employed to prevent child abuse), as well as the promotion of available geriatric services, would lead to a significant improvement in both the notification and outcomes of abuse. Important geriatric services include respite care and family counseling(2). The value of Lothian and Philp’s article is in its recognition that the dignity and autonomy of elders are being compromised. We must make the community and our health care workers aware that elder abuse is a problem. References: 1. Lothian K. Philp I. Care of older people: Maintaining the dignity and autonomy of older people in the healthcare setting. BMJ. 322: 668-70, 2001 Mar 17 2. Kurrle S. Sadler P. Cameron I. Elder abuse – an Australian case series. Medical journal of Australia. 155(3): 150-3, 1991 Aug 5. 3. Silverman J. Hudson MF. Elder mistreatment: a guide of Medical professionals. NCMJ. 61(5): 291-6, 2000 Sept/Oct. 4. Williams-Burgess C. Kimball MJ. The neglected elder: a family systems approach. Journal of psychosocial nursing and mental health services. 30(10): 21-5, 1992 Oct. 5. Kruger MRM. Moon CH. Can you spot the signs of elder mistreatment? Postgraduate medicine. 106(2): 169-83, 1999 Aug. 6. Bradley M. Caring for Older people: Elder abuse. BMJ. 313: 548-550, 1996 Aug |
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A J D Macdonald, Professor of Old Age Psychiatry University Hospital Lewisham
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EDITOR Dignity & Autonomy in Older people- wrong diagnosis, wrong treatment While I applaud the appearance of an article on the dignity and autonomy of older people in the healthcare setting(1) I cannot agree with its content. I have put forward the view in the dementia care literature(2) and the press(3) that British healthcare is failing older patients as a consequence of system-wide abuse of staff, managers, purchasers and politicians. As long as this corrosive, self-sustaining culture remains untouched, it is simply impossible to improve the dignity and autonomy of any group at all, let alone the more disadvantaged ones. What Lothian & Philp call the "anecdotal" evidence of a continuing, serious problem is already overwhelming and still growing, graphically portrayed in last week’s Panorama TV programme. As I write, a 91-year-old family member has finally and properly arrived in a hospital bed after being taken to A&E having fallen down the stairs. She fractured 3 ribs and sustained a severe, immobilising calf injury. She spent 8 hours, until 3am, in hospital A's A&E department on a trolley. She was then admitted to a ward for 6 hours, then transferred to hospital B where she spent 10 hours in A&E on a trolley, without food or drink until her daughter arrived, until she was admitted to a ward there. After 18 hours she was deemed unsuitable and transferred back to hospital B where waited again on a trolley in A&E before her daughter became very distressed and made a formal complaint, upon which a bed was found for her, although in a palpably unpleasant atmosphere. At no point did she receive any considered investigation or treatment. Several dedicated, hard-worked and kind NHS staff watched this happen to a 91-year-old with apparent insouciance. If you can tell anything at all about theory at all from the current raft of DOH documents(3,4), the government appears to explain this outrage (both what happened and what did not happen) in terms of either the absence of clear and agreed standards or, like Lothian & Philp, inadequacies in training. The evidence for the former is overwhelmingly negative, and for the latter at best scanty. We must stop wasting time and energy on standards and frameworks- they simply add to the abusive cycle and make things worse. We must also stop the abusive scapegoating of front-line staff by suggesting that retraining will help. Until we lift up our eyes at the whole system, away from the patient and the staff immediately involved, we will never be able to prevent this sort of outrageously degrading treatment, and should all go and live in France. Yours truly A.J,D Macdonald
Competing interests: none References 1. Lothian K, Philp I (2001) Maintaining the dignity and autonomy of older people in the healthcare setting. BMJ 322; 667-70 2. Macdonald. A (2000) The vicious circle of the system. Journal of Dementia Care 8 (5) 15-16 3. Macdonald A (2001) Where the buck stops. Guardian Society January 31 2001 p111 4. Department of Health (2000) The National Plan. London, DOH 5. Department of Health (2001) National Service Framework for Older People. London, DOH |
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