Ethical issues in the care of older people

Rees, King and Schmitz (2009) conducted a literature review in Australia, where they explored ethical issues in the care of older people from a nursing perspective. Some of the research reports they reviewed showed that nurses perceived doctors as one source of ethical issues.

Specific ethical issues relating to doctors were, for example, their inability to discuss issues, poor decision making, inadequate pain management, overtreatment as well as undertreatment of patients, focus on cure and inability to attend to patients’ wider needs, and their lack of knowledge of palliative care. Conflicting interests in the families of older people were also reported by nurses as a source of ethical issues in the analysed studies.

Rees et al. (2009) present a few examples where family members intervene in the patient’s decision: a) a patient stopped eating, and a relative wanted to feed the patient by force; b) situations where a relative sought extreme forms of treatment regardless of the patient’s suffering or her own wishes, and c) a patient who did not wish important information to be disclosed to her relatives. Rees et al. argue, based on their findings, that ageism (paternalism because of the patient’s age) is one of the major sources of the ethical issues that nurses face in the care of older people.

Teeri and her colleagues conducted several studies (2006, 2007a, 2007b, 2008) with the purpose of describing ethical problems experienced by patients, relatives and nurses in long-term care institutions. They found out that problems related to the self-determination of the older people were reported by all three groups of respondents. Nurses were quite well aware of this aspect of patients’ rights and have higher expectations in this respect.

Teeri et al. reported that the institutionalised elderly patients have only very limited opportunities to influence their own care. They argue tha on average such opportunities are less readily available than patients would want and expect. Patients’ wishes concerning their daily lives frequently conflict with the schedules of the ward.

Teeri and her research group were especially interested in the integrity of older patients in the institutions. From the point of view of integrity, a major ethical difficulty is that elderly patients are deprived of control over their daily lives. Results indicated that most of the relatives in their studies had a relatively positive assessment of how the integrity of older patients is maintained in long-term  care institutions.

The relatives were quite satisfied with the maintenance of the patient’s physical integrity and reasonably pleased with their physical treatment. The longer the patient had been institutionalised, the more satisfied the relative was with the patient’s physical treatment. Although the relatives were reasonably satisfied with the care, the results for physical integrity challenge the health care providers to reflect on their way of working.

As Teeri et al. observed, the patients were touched without their permission, and nurses entered the patient room without knocking. Nurses also limited the movement of their patients by tying them to a chair or to their beds. Tying is very problematic, and it conflicts with professional ethics. Teeri et al. mentioned that physical restraint should only be used as the last resort, when there is no alternative to caring well for a patient in long-term care institutions.

Patients can also be restrained chemically by the excessive use of sleeping pills and tranquillisers, but the majority of nurses took the view that their patients were not receiving excessive medication. As Teeri et al. mentioned, studying the ethical problems involved in medication is by no means unproblematic.