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. 2001 Aug 11;323(7308):340.
Maintaining older people's dignity and autonomy in healthcare settings
Whole system must be looked at to prevent degrading treatment
Editor—Unfortunately, I cannot agree with Lothian and Philp in their article on the dignity and autonomy of older people in the healthcare setting.1 On several occasions I have put forward the view that British health care is failing older patients as a consequence of system-wide abuse of staff, managers, purchasers, and politicians.2,3 As long as this corrosive, self sustaining culture remains untouched it is impossible to improve the dignity and autonomy of any group, let alone the more disadvantaged ones. What Lothian and Philp call the anecdotal evidence of a continuing, serious problem is already overwhelming and is still growing.
Recently, a 91 year old family member was finally given a hospital bed after being taken to an accident and emergency department after falling down the stairs. She had fractured three ribs and sustained a severe, immobilising calf injury. She spent eight hours, until 3 am, in hospital A's accident and emergency department on a trolley. She was admitted to a ward for six hours and then transferred to hospital B, where she spent 10 hours in the accident and emergency department on a trolley, without food or drink until her daughter arrived, before being admitted to a ward.
After 18 hours she was transferred back to hospital A, where she waited again on a trolley in the accident and emergency department. Her daughter became distressed at this and made a formal complaint, whereupon a bed was found, although the atmosphere was unpleasant. At no point did she receive any considered investigation or treatment.
Several dedicated, hard working, and kind NHS staff watched this happen with apparent indifference. If you can tell anything at all about theory from the current raft of documents from the Department of Health3,4 the government seems to explain this outrage (both what happened and what did not happen) in terms of either the absence of clear and agreed standards or, as Lothian and Philp do, 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 frameworks5: they simply add to the abusive cycle and make things worse. We must also stop the scapegoating of frontline staff by suggesting that retraining will help. Until we look at the whole system, away from the patients and staff immediately involved, we will never prevent such degrading treatment.
References
1.Lothian K, Philp I. Care of older people: Maintaining the dignity and autonomy of older people in the healthcare setting. BMJ. 2001;322:667–670. doi: 10.1136/bmj.322.7287.668. . (17 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Macdonald A. The vicious circle of the system. J Dementia Care. 2000;8:15–16. [Google Scholar]
3.Macdonald A. Where the buck stops. Guardian Society 2001 Jan 31:111.
4.Department of Health. The national plan. London: DoH; 2000. [Google Scholar]
5.Department of Health. National service framework for older people. London: DoH; 2001. [Google Scholar]
BMJ. 2001 Aug 11;323(7308):340.
Elder abuse is both community and healthcare issue
Editor—Lothian and Philp emphasised that the maintenance of an older person's dignity and autonomy is essential in a healthcare setting.1-1 They pointed out how this could be compromised by the insensitivity and disrespect of healthcare workers. But the negative comments of older service users and their carers that are quoted in the article seem to indicate more than just insensitivity. Some of them border on the deprivation of an older person's autonomy and dignity; this would be more appropriately termed elder abuse.1-2
Roughly 3-5% of Australians aged over 65 suffer elder abuse,1-2 and these figures are similar to those in the United States.1-3 Only 1 in 14 cases is thought to be officially reported.1-4 The perpetrator is the victim's spouse in over half the reported cases and an adult son or daughter in a quarter.1-2 Elder abuse may be physical, psychological, or financial; neglect is also a form of abuse.
Few prevalence studies with carefully defined catchment populations are available in Australia.1-2 There is also a dearth of intervention studies for elder abuse.1-2 Few guidelines have been provided to healthcare workers with regard to the management and reporting of suspected abuse. These workers are required by law to attend child protection programmes, but no such educational schemes exist for the protection of elderly people. Because so little attention is devoted to elder abuse many cases go unreported.1-5
Lothian and Philp proposed that a lack of education and training in hospitals predispose elderly people to this kind of abuse.1-1 They contended that “a key means of tackling poor attitudes by staff towards older people is through extensive and continued training.” The healthcare setting has a vital role as a place of refuge for abused elderly people and gives healthcare workers an opportunity to identify abuse before it progresses. But focusing on abuse in these settings alone is too simplistic; elder abuse occurs elsewhere as well.
Wider community education is required as a primary preventive measure. Public awareness programmes outlining the prevalence and impact of elder abuse (similar to those used to prevent child abuse), as well as the promotion of geriatric services, would lead to a considerable improvement in both the notification and outcomes of abuse. Important geriatric services include respite care and family counselling.1-2
The value of Lothian and Philp's article is in its recognition that the dignity and autonomy of older people are being compromised. We must make the community and our healthcare workers aware that elder abuse is a problem.
References
1-1.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. doi: 10.1136/bmj.322.7287.668. . (17 March.) [DOI] [PMC free article] [PubMed] [Google Scholar]
1-2.Kurrle S, Sadler P, Cameron I. Elder abuse—an Australian case series. Med J Aust. 1991;155:150–153. doi: 10.5694/j.1326-5377.1991.tb142179.x. [DOI] [PubMed] [Google Scholar]
1-3.Silverman J, Hudson MF. Elder mistreatment: a guide for medical professionals. N C Med J. 2000;61:291–296. [PubMed] [Google Scholar]
1-4.Williams-Burgess C, Kimball MJ. The neglected elder: a family systems approach. J Psychosoc Nurs Ment Health Serv. 1992;30:21–25. doi: 10.3928/0279-3695-19921001-07. [DOI] [PubMed] [Google Scholar]
1-5.Bradley M. Caring for older people: Elder abuse. BMJ. 1996;313:548–550. doi: 10.1136/bmj.313.7056.548. [DOI] [PMC free article] [PubMed] [Google Scholar]
