Elder abuse, 21st century style
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7544.801 (Published 30 March 2006) Cite this as: BMJ 2006;332:801All rapid responses
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Good article. As a GP I agree and admit to being guilty on occassion
especially when on call for the huge structures now providing out of hours
'care'. What is not discussed though is the fear the homes have of being
accused of failing to 'care' by the adult abuse system. There is now real
worry that a resident dying in a home might attract enquiry from social
services.
Competing interests:
None declared
Competing interests: No competing interests
Dr Fisken is quite correct to insist on a comprehensive psychosocial
history to define each patient.
But is this possible in this climate of efficiency savings,
objectives, targets and outcomes? Or indeed is it possible when we no
longer look after patients but serve consumers and customers, we are no
longer doctors but mere providers? Is it surprising that the humanity has
disappeared from care of the patients when it appears to have all but
departed from the health service?
Competing interests:
None declared
Competing interests: No competing interests
I read this article with concern as it represents an accurate account
of my experiences as a GP .
Many eldely patients who register at our surgery from nursing homes
arrive with a carer who often knows little about their medical problems.
There are no previous GP notes,no clinical summaries , no medication
details and no simple ,practical and immediate method to access them . We
are frequenly confronted with patients who have multiple pathology and who
are demented, language problems exacerbate this scenario. Calls and letter
to nursing homes to explain that the paucity of information compromises
our clinical care does not achieve improvment .
How can we provide information to hospitals when our base-line
knowledge is minimal ?.It may takes weeks or months to obtain from the
relevant authorities.
I believe that the most vulnerable elderly patients deserve better.
This could be achieved by a PIP which should be mandatory information
before the patients is admitted to the nursing home and sees the new GP. It should contain the following (all of which should be on the current
GP's notes):
A computer generated GP summary and medication.
Selected hospital letter(s)
social aspects of the patient eg family
Competing interests:
None declared
Competing interests: No competing interests
I agree wholeheartedly with Roger Fisken that it should become
routine that patients, families and their health professionals in the
community are engaged in discussion about the level of treatment they
would want before a ‘crisis point’ is reached and they are not longer able
to express their wishes. However, I object to the repeated statements
throughout his article that the failings in this respect lie with junior
doctors and nursing staff.
In my own experience both as a student and in teaching students from
several different medical schools, I believe that the truth is quite the
opposite – most doctors’ interest and competence in taking a social
history is at a peak on the day they leave medical school. From their
first shift as house officers, it is rapidly quelled by busy and
disinterested seniors who roll their eyes and tell them to ‘hurry up’ when
they reach that part of their history-taking. Then, as juniors are under
pressure to assess patients increasingly rapidly with each on-call that
goes by, the social history is relegated to a one-liner, if it survives at
all under the pressure of the ‘four-hour wait’ in A&E.
All is not lost for the social history, however – it may be
resurrected later in our careers. I was delighted to find a sea-change in
consultant’s attitudes when I moved into paediatrics, and found that there
was a page and a half on our clerking proformas devoted to the subject,
and that consultants gave equal interest to the child’s family situation
as to the medical complaint. Now, having changed to psychiatry, the social
history has reached a peak of importance I never thought possible – and my
enjoyment of caring for my patients is so much the better for
understanding more about their lives.
1. Fisken, R.A. Elder abuse, 21st Century style. BMJ 2006; 332: p801.
(18th March).
Competing interests:
None declared
Competing interests: No competing interests
Dignity in the elderly
Fisken raises several valid points throughout the editorial. In this
highly
politicised area of healthcare, dignity is everything. However too often
as the
admitting medical SHO, one is bewildered as to how to proceed. The patient
may well be in the terminal phase of life, but the ambulance has been
called
and the relatives are highly charged and want healthcare intervention even
when (in my limited experience) this is neither feasible or realistic.
The problem is compounded by the community, whereby nursing homes
often have no pre confirmed plan as to how to proceed with the elderly
acutely unwell patient and a distress call is passed to the out of hours
general
practitioner. Whereas the regular general practioner has detailed medical
records and assessment of the patient, the out of hours co-operative has
not.
It has no interest in actually assessing the pt and the automatic, quite
often
telephonic advice is ‘ to call the ambulance and give them some
paracetamol’.
I do not believe that junior doctors are taught badly, and Fisken’s
statement that ‘Junior staff seem to think that a social history is all
about
place of residence and crude process issues such as washing,
dressing,feeding and mobilising’ is underestimating the necessities of
life
itself. Yes, there is more to life but if the patient is limited in one of
the above
core skills, surely this should be addressed as part of the overall
admission to
hospital, if thought that this is possible and pleasure enhancing.
Unfortunately whilst on call, I would love to empathise and discuss issues
with my patients, however the spectre of a ‘breach’ and bed managers loom
large. There is also almost always yet another patient to see and hence
the
social history has to be conduced into the activities of daily living.
The current climate dictates that we, as the medical profession have
to
be seen to have done everything up till failure. This is crass, and people
have
to remember and understand that death comes to us all, eventually, no
matter how long one lives. I agree that a futile thirty minute ambulance
journey and numerous invasive investigations later is a pitiful and most
undignified way to die.
Fisken RA. Elder Abuse, 21st Century Style. BMJ 2006;332;801(1st
April)
Competing interests:
None declared
Competing interests: No competing interests