Personal Views: Elder abuse, 21st century style
Authors: Roger A Fisken
Journal: BMJ (2006)

We hear a lot about the right of people to “die with dignity.” Such discussions usually occur in the context of malignant disease or other major progressive illnesses such as motor neurone disease. In a week in which a report has focused attention on the care of elderly people (see BMJ 2006;332: 746), it is surely worth highlighting the problem of undignified death in those who simply have multiple that nursing homes, hospitals, and general practitioners have to this problem leads to a series of defects in the care of such people. It is a form of elder abuse that is becoming increasingly common.


There needs to be a sort of “Do not attempt aggressive medical treatment” order that could be applied to frail people in the community


Frail people admitted to nursing homes have a high probability of dying, yet the staff of the home rarely seem to ask the question: “If you (or your relative) become seriously ill, what do you want us to do? What level of medical care do you want us to provide?” Surely, by analogy with “Do not attempt resuscitation” orders in hospital, there needs to be a sort of “Do not attempt aggressive medical treatment” order that could be applied to frail people in the community. This is not about denying people the care that they need, it is simply about recognising that high tech medical care is often distressing, futile, and expensive.


Why are we still teaching students and junior doctors so badly that they cannot take a proper social history?


General practitioners admitting people to hospital frequently fail to provide any statement of what the hospital admission is intended to achieve. I realise that this may be a difficult area for GPs who do not know the patient and a busy GP may not have time to question the nursing home staff about the patient's medical and social background. However, the centrality of this question in the planning of the patient's overall care needs to be recognised and it would at least be helpful if the GP could indicate something about how this information might be obtained and which relatives are involved.

Junior doctors and ward nurses frequently take a totally inadequate history from such patients and their carers. When I asked about the normal state of health of one patient, I was told: “He's fairly mobile—he can usually get from the lounge to the dining room with his Zimmer frame.” This told me nothing about what life meant to the patient, what he enjoyed or did not enjoy, or what kind of place he occupied in the great human family. 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. Most of us don't live in order to wash, feed ourselves, and get dressed in the morning: we live in order to enjoy company, to read, to watch television, to play games, to write, to do a million other things that differentiate us from narcotised laboratory mice. Why are we still teaching medical students and junior doctors so badly that they cannot take a proper social history?

I am not sure whether this form of elder abuse is due to lack of thought, poor training, or a fear of being criticised if one does not take active measures in every possible case. What I am sure of is that people who can benefit from an acute hospital admission should invariably be admitted and managed as actively as possible. Those who cannot benefit from such a disruptive and alarming intervention should be recognised early on and given every care and attention so that they do not suffer—this includes acknowledging that hospital admission is futile and avoiding it. Finally, I am sure that we can do better and that we must train our junior medical and nursing colleagues as to how they can do better.