Ethical issues for older people in the emergency department

Maile, E L; Harrison, Jennifer; Chikura, Gertrude; Russ, Kate; Conroy, Simon

doi:10.1016/j.eurger.2016.02.005

Cited by 2 publications

(1 citation statement)

References 31 publications

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“…The hospitalization of polypathological seniors represents a break in their life course. The technicity of medical care is generally engaged in a systematic way and often contributes to acute decompensation [ 26 ]. However, even though some medical interventions (e.g., insertion of a venous catheter for hydration or antibiotic therapy, additional medications, bandaging, biological check-ups) may seem, in the best interest of the patient, acceptable and necessary according to caregivers, and as such, compatible with internationally recognized legal and moral safeguards, their implementation may lead to vehement or even violent opposition if they exceed patient’s tolerance and dependence threshold [ 27 ].…”

Section: Hypothesesmentioning

confidence: 99%

Investigation of opposition to diagnostic or therapeutic procedures in older people hospitalized in acute geriatric services: the OPTAH pilot study protocol

Tannou

Trimaille

Mathieu-Nicot

et al. 2020

Pilot Feasibility Stud

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Background Shared decision-making is a process that involves collaborative discussions between a patient and a care team to ensure informed healthcare decisions. This process becomes more complex when the older person’s decision-making capacities are affected. In these situations, surrogate decision-making processes are used to define a person-centered care plan. Despite these processes, the implementation of the care plan defined in the best interest of the patient may nevertheless be rejected by the patient, particularly in cases of neurocognitive disorders or delirium. This concept of opposition and/or refusal is frequently used in research. This is not yet well understood in the medical literature, and there is a lack of consensus on its definition. We, therefore, explored this concept by defining opposition to diagnostic or therapeutic proposals. Method Our pilot study protocol is based on a mixed methodology (epidemiological and qualitative research) to quantify this phenomenon, validate the proposed definition, and explore its core elements. Opposition and refusal of care will be quantified, and semi-structured interviews will be conducted with patients, their relatives, and referring carers. Multidisciplinary meetings that will be associated with these situations will also be observed and analyzed. Methodological approaches that can be used to explore opposition and refusal of care in a scientific, reproducible framework are presented. This methodology considers the specificities of the geriatric, polypathological population with neurocognitive disorders. Discussion Opposition and refusal of care are key concepts in clinical research on ethics, particularly in the geriatric field. These concepts are frequently mentioned in studies involving older patients but have not been specifically defined or studied. This study would undoubtedly lead to greater awareness among professional caregivers and relatives of the significance of such opposition, and more respectful interactions in these complex hospitalization cases. Trial registration ClinicalTrial.gov, NCT03373838. Registered on 14 December 2017.

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Section: Hypothesesmentioning

confidence: 99%

Investigation of opposition to diagnostic or therapeutic procedures in older people hospitalized in acute geriatric services: the OPTAH pilot study protocol

Tannou

Trimaille

Mathieu-Nicot

et al. 2020

Pilot Feasibility Stud

View full text Add to dashboard Cite

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What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Preston

Chambers

Campbell

et al. 2018

Health Serv Deliv Res

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BackgroundEmergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address.ObjectivesTo systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes.DesignA systematic mapping review.SettingEvidence from developed countries on interventions delivered in the ED.ParticipantsFrail and high-risk older people and general populations of older people (aged > 65 years).InterventionsInterventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED.Main outcome measuresPatient outcomes (direct and indirect) and health service outcomes.Data sourcesEvidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016.Review methodsA review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made.ResultsOf the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes.LimitationsThis review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review.ConclusionsA substantial body of evidence on interventions for frail and high-risk older people was identified and mapped.Future workFuture work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients.Study registrationThis study is registered as PROSPERO CRD42016043260.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Ethical issues for older people in the emergency department

Cited by 2 publications

References 31 publications

Investigation of opposition to diagnostic or therapeutic procedures in older people hospitalized in acute geriatric services: the OPTAH pilot study protocol

Investigation of opposition to diagnostic or therapeutic procedures in older people hospitalized in acute geriatric services: the OPTAH pilot study protocol

What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

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