Ensuring dignity in the care of older peopleBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e533 (Published 26 January 2012) Cite this as: BMJ 2012;344:e533
- Jackie Morris, honorary research associate
- 1UCL Research Department of Primary Care and Population Health, Royal Free Hospital, London NW3 2PF, UK
The Patients Association annual report, We’ve been listening, have you been learning?, was published in November 2011. It detailed 16 accounts of poor hospital care, of predominantly older people, heard by its helpline in the past year.1 The report focused not only on the care patients received from nurses, but also on experiences of care from other professionals, including doctors.
Poor communication; a lack of empathy; and a failure to listen, respond, or explain were common complaints. Impaired hearing and sight often went unnoticed. The report highlighted failures to promote control, continence, and independence and a reluctance to give people time to be heard. It also noted poor pain control and poor management of distress, which led to inadequate end of life care. Relatives explained how disturbed they were to see patients ill-kempt, with dirty fingernails and soiled clothes. Hospital wards were often described as dirty and unhygienic. The cases illustrated the humiliation of being left in soiled sheets as patients were told to pass urine and faeces in their beds because it was easier for staff to change sheets than to take them to the toilet. Patients were not encouraged to eat or drink, and food and water were often out of reach. In some cases nobody seemed to be in charge, and absence of continuity led to inadequate care. Poor multidisciplinary collaboration, communication, multiple transfers between wards, and a lack of leadership were all highlighted as components of undignified and inhumane care in hospital.
Such components of inhumane care were also identified in the British Geriatrics Society led campaign, Do not Forget the Person, launched in 2010.2 Recent reports from the Health Service Ombudsman,3 the Care Quality Commission,4 and the Equality and Human Rights Commission5 have also shed light on some appalling practices in care. The mid Staffordshire catastrophe,6 which led to an independent inquiry, highlighted failures of staff to deliver person centred care in hospital, in some cases ignoring patients and other individuals with fatal consequences. The final report of the mid Staffordshire inquiry is awaited with interest, and it promises to include a recommendation to have a senior geriatrician on every elderly care ward and standards for the recruitment, training, and regulation of healthcare support workers and nurses who care for older adults.
Population ageing has led to an increase in the prevalence and proportion of older inpatients with complex physical and mental health problems. A recent prospective study reported that a quarter of patients over 70 undergoing acute admission have dementia.7 However, the 2011 national audit of dementia care in general hospitals showed that only 6% of 210 hospitals had a care pathway for people with dementia, only 6% of those with dementia were administered a test of cognition on admission and discharge, a quarter of hospital notes did not include an assessment of pain, and only 5% of hospitals required staff to be trained in the care of patients with dementia.8 Assessments of nutritional status were performed in only 70% of the sample of case notes examined in the audit. Less than half of medical notes audited had a special place for information about people with dementia.
A more recent prevalence study conducted in a general hospital found that 50% of people over 70 years admitted to hospital had cognitive impairment, 27% had delirium, 24% had possible major depression, and 8% had definite major depression, 8% had delusions, and 9% were agitated or aggressive.9 In addition, 47% of patients admitted were incontinent, 49% needed help with feeding, and 44% needed major help with transfers—for example, from bed to chair or bed to toilet. General hospital staff may feel ill equipped to deal with the increasing proportion of older adults admitted as an emergency with physical problems who also have mental health problems or cognitive deficits. The Preventing Abuse and Neglect in the Care of Older Adults (PANICOA) study—a qualitative study of older patients, their carers, and hospital staff commissioned by the Department of Health for England and Wales—found that older patients often described acute hospital wards as “confusing and inaccessible” and staff expressed the almost unanimous view that the acute hospital is not “the right place” for older people.10 The authors concluded that hospital wards were not fit for purpose as places to treat people over 65, which is difficult to ignore when such people account for most hospital users.
A Royal College of Nursing project that undertook several surveys of more than 700 professionals and almost 1500 family carers, supporters, and people with dementia, found that older people with dementia have more complications and stay longer in hospital than those without dementia.11 The researchers concluded from their respondents that staff should be informed, skilled, and have time to care; that family carers and friends should be involved, unless the person with dementia indicates otherwise; and that all patients aged over 70 should be offered cognitive assessment to support early identification of cognitive impairment and the delivery of appropriate care. Care plans should be multidisciplinary—supporting nutrition, comfort, and control—and should be based on the clinical, physical, emotional, cognitive, and physical needs of the individual. What should apply to patients with dementia could apply to most older people.
The imminent publication of the Commission on Improving Dignity in Care by the NHS Confederation, Age UK, and the Local Government Association is awaited with interest.12 Hopefully, it will make all hospital and community doctors aware that it is every doctor’s responsibility to know about and have skills to care for and treat older people with complex conditions or frailty (or both). In future, undergraduate and postgraduate training will need to ensure that all doctors are trained to work in a holistic, humane, and multidisciplinary way that respects the dignity of patients. The Patients Association report applies to all who work with older adults and not just nurses.
Cite this as: BMJ 2012;344:e533
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; JM has done work for Barchester Healthcare and Jewish Care (teaching and looking at the healthcare in their care homes); she is British Geriatrics Society dignity champion and a member of the Dignity Council.
Provenance and peer review: Commissioned; not externally peer reviewed.