Helen Salisbury: Balancing patient safety and autonomyBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4948 (Published 20 August 2019) Cite this as: BMJ 2019;366:l4948
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We read with interest the paper entitled ‘Balancing patient safety and autonomy’ by Helen Salisbury (1).
Beneficence and autonomy are two core principles of medical ethics which can conflict with one another in countless situations. This dilemma often presents in the care of the elderly, as diseases that potentially compromise capacity start to frequent.
Old age can put individuals in a very vulnerable position. In clinical practice, we have spoken to individuals who mourn the loss of what they hold dear – these factors include fitness, health or even companions of similar age groups. However, these patients have one thing in common – they yearn to maintain the right to choose how the remainder of their lives are led. On placement we have especially been impressed by the elderly who are independently able to manoeuvre their wheelchairs within the small space of a rheumatology clinic, remark on the excitement of having had their hair done and remain enthusiastic within their social groups and clubs/activities. However, it is often during this age that health professionals’ step in to prioritise patients’ safety above autonomy. Often, this can be unintentional – some patients may not realise that a ‘dizzy’ feeling first thing in the morning is down to a side effect of a medication which has perhaps not been addressed within consultations. A simple consultation with an adjustment of dose can enable patients to partake in their usual activities and feel in control of their daily routine. It’s often the simplest adjustments that not only enhance independence in daily life but also better the medical care of an individual. These factors may however be left unnoticed and their impact underestimated if an individual appears ‘vulnerable’ or ‘frail’ on appearance.
Autonomy aside, why should we solely focus on physical needs and disregard the patient as a holistic being – whose psychosocial needs require attention too? As medical students, we are always asked to enquire on a patient’s quality of life – and in our experience, it is often an inability to travel, make friends and socialise that can dampen a patient’s mood. If such factors are encouraged by healthcare professionals (alongside appropriate education), we may see better adherence to lifestyle advice and medication.
Often patients are deemed to be unsafe to live on their own, and therefore have to move to care homes. It may not be surprising then, that depression is twice as common (40% of patients) in those in care homes, compared to those in the community who are housebound (2). As medical students, we are encouraged to partake in quality improvement activities. However, these seem disproportionately focussed around primary and secondary care. A large majority of the elderly seek care in the community, be it through house visits from healthcare professionals or within care homes, so perhaps we should refocus our attempts to improve freedom of the elderly in this environment. Such interventions do exist in the form of group activities (i.e. arts and music) within a care home setting, interacting with volunteers and ‘shopping’ trips. However, perhaps it is up to us as caregivers to encourage the elderly to participate. This will ensure they are able to explore as much of the world as they desire, and offer them the opportunities available for personal development.
1) Salisbury, H. (2019). Helen Salisbury: Balancing patient safety and autonomy. BMJ, p.4948.
2) Faculty of Public Health, Mental Health Foundation. Better Mental Health for All: A Public Health Approach to Mental Health Improvement (2016).
Competing interests: No competing interests