Recent rapid responses

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We read this excellent article and specially noticed the findings of the ‘Patients Association’ annual report: ‘We’ve been listening; have you been learning? It specifies ‘unnoticed hearing impairment’ as one of the example of poor hospital care of elderly patients.

Following this publication, we performed an audit in our hospital and realized that neither nurses nor the doctors tend to record hearing status of all elderly patients. Even if hearing impairment is noticed, no one seemed to be taking action to rectify it. We are now taking steps to make sure that we all take some action to manage their hearing impairment if identified, e.g. reminding the GP to refer these patients to audiology or to arrange a hearing aid for some patients while they are in the hospital if they have severe impairment. We wish to thank the author to make us aware of this important finding and we feel proud to act on this.

Competing interests: None declared

Narveshwar Sinha, GP Specialty trainee

Dr Jason Raw and Dr Shabana Zafar

Fairfield General Hospital, Pennine Acute NHS Trust, Bury, Rochdale Old Road, Bury BL9 7TD

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5 February 2012

Another hip on the trauma list: 'half-real' bones in a 'half-real' patient. But look again with better eyes - beneath the wrinkles see the face: of the baby weighed, the child that played, the young fair maid & the mum that gave. What an amazing person to meet today: amazingly real!

Maia Graham MSc

Mark Davies FRCA

Royal Liverpool & Broadgreen University Hospitals NHS Trust.
No external funding and no competing interests declared.

Competing interests: None declared

Mark W Davies, Anaesthesia

Maia Graham

Royal Liverpool & Broadgreen University Hospitals NHS Trust, Liverpool L7 8XP

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To the editor,

Dear Sir,

Beating the breast of medical institutions will hardly solve the problem of poor care meted out to the elderly hospital population, but there needs to be some analysis of the shocking statistics in the Patients Association report. Throwing out varying percentages of the frequency of dementia among patients over 70 is lacking in meaning if the definition of dementia is not spelled out. Many elderly are far from being demented but become slightly confused in unfamiliar surroundings. Young people also respond differently when plunged into unfamiliar surroundings, hence some of the sudden changes in behaviours seen in those who have joined the military or moved to a distant university. Hospital staff often have no idea which patients are truly suffering from dementia and which are disoriented as a result of hospitalisation. Their handling of patients is inappropriate as a result.

And one must question whether deliberate institutional policies can cause disrespect to patients. Policy may discourage patients from using the toilet because of risk of falls and injuries, though the use of adult diapers is more humiliating and embarrassing and produces skin rashes. But a fall might be fatal, while humiliation is just that. Hospitals may encourage time consuming charting by hand and at the computer in order to document every detail of care, but as a result nurses no longer have the time to converse with patients and discover their cognitive acuity.

Further, we have no way of knowing how many of the complaints submitted to the Patients' Association were valid, and how many were written by the family members of demented patients who could not bear to be present caring for their loved ones, and so they send flowers, and write mean complaint letters.

The ethics of maintaining the dignity of the elderly patient should be paramount. Healthcare professionals should be held accountable to ensure that continuity of care persists even in the geriatric setting. Perhaps those managing the clinical care of the elderly can learn from successful quality improvement approaches that have been adopted in the intensive care unit, another system that is wrought with major managerial obstacles. 1

The causes and effects leading to inappropriate care of the elderly should be clearly mapped. To what extent will the presence of a senior geriatrician on every elderly care ward address and diminish inadequate end of life care? Will the presence of a senior geriatrician lead to patient-centred outcomes, when there is non-uniformity in the regulation of end of life care practices across the board?

Ensuring dignity in the care of older people will require a team-oriented culture of supportive leadership, effective coordination, timely communication, and open problem solving approaches which by far exceed the strategies highlighted in the article. 2

1. Strosberg MA and Teres D..Gatekeeping in the Intensive Care Unit.1997.Health Administration Press.
2. Shortell SM et al. “ Continuously Improving Patient Care” Quality Review Bulletin 18: 150-155, May, 1992. Oak rook Terrace, IL.: Joint Commission on Accreditation of Healthcare Organizations.

Sincerely yours,
Andem Effiong and Rabbi Avrohom Marmorstein

Competing interests: None declared

Andem Effiong, Instructor

Rabbi Avrohom Marmorstein, Chaplain, Department of Pastoral Care, HackensackUMC Graduate student, Joint program in Bioethics, Mount Sinai School of Medicine and Union Graduate College.

Georgetown University Medical Center, 4000 Reservoir Rd NW Washington DC 20007 USA

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