Care with compassion

An aging UK population means that trainee doctors will increasingly face older patients with multiple morbidities. MDDUS adviser Dr Greg Dollman offers advice

THE number of people in the UK aged over 65 now outnumbers those under 16 for the first time, with life expectancy rates predicted to hit almost 86 years for men and 88 for women by 2030.

While falling mortality rates are to be welcomed, this raises important issues for trainees. The growing elderly population has significant (and often complex) medical needs and doctors are increasingly required during their training to undertake clinical rotations caring for older patients.

These challenging jobs provide doctors with the opportunity not only to increase their professional and clinical skills but also to offer holistic care, working with patients and those close to them as well as the broader healthcare team.

In recent years concerns have been raised in the media regarding the care of older patients. These revelations have resulted in far-reaching inquiries and investigations, with subsequent changes to law and greater professional education and guidance. For example, The Care Act 2014 places a duty on doctors to take necessary steps to protect adults at risk of abuse or neglect, and the General Medical Council (GMC) regularly updates its guidance Better care for older people.

Clearly older patients will often have increased physical and mental health needs compared with other patients, but individual care should be structured around the key elements of compassion, respect and the preservation of dignity.

Do not discriminate, do not rush

The GMC’s Good medical practice states that a doctor must be polite and considerate, and must not discriminate against patients. When caring for older people, doctors must be patient and respectful, working in partnership to share with them the information they will need to make decisions about their care. Doctors must learn to adapt their usual frenetic pace, taking the necessary time to consult with older patients. These encounters may be slower than with other patients, owing to physical limitations (from sensory impairment to mobility issues) or cognitive concerns.

Mental capacity

In England and Wales, the Mental Capacity Act 2005 (MCA) holds that all adults are presumed to have capacity unless it is proved otherwise, while the Adults with Incapacity (Scotland) Act 2000 makes similar provisions north of the border. Both state that a doctor must not assume that a patient is unable to make their own decisions owing to their age or medical condition. An older patient may, however, require assistance and a doctor has a statutory duty to encourage and support people in reaching their own conclusions. Even if a patient is found to lack capacity, the laws state that the person must be involved as far as possible in decision-making.

Learn to adapt your usual frenetic pace, taking time to consult with older patients

Decline in cognitive functioning, owing to acute or chronic conditions such as delirium and dementia respectively, may affect an older person’s ability to make a particular decision at a particular time. The MCA is regarded as a two-stage functional test of capacity: an impairment of or disturbance in the functioning of the mind or brain must exist, which sufficiently affects a person’s capacity to make a particular decision. A patient will be considered to lack the capacity to make a decision if they are unable to understand, retain and weigh up the information relevant to the decision, and communicate this decision (by any means). If a patient is only temporarily unable to make a choice, decision-making should be postponed if at all possible to a time when the patient has capacity. All doctors should be able to undertake this essential assessment, and should seek the assistance of a senior member of the multidisciplinary team if they are in doubt as to a patient’s capacity.

Involving loved ones

An older person with capacity may ask that a family member or another person close to them make decisions on their behalf. The GMC’s Consent guidance reminds doctors that no one else can make a decision on behalf of an adult who has capacity. A doctor should explore a patient’s wish not to be involved in decision-making, and should respect this as far as possible (certain information must still be shared, such as that required in order to give consent to a proposed investigation or treatment).

Similarly, those close to an older patient may wish to discuss their concerns about the patient’s health. The GMC’s Confidentiality guidance states that a doctor should not refuse to listen to a patient’s partner, carers or others on the basis of confidentiality, but must consider whether the patient would regard such a discussion as a breach of trust (especially if they have asked the doctor not to involve certain people).

In the absence of an advance decision or legal authority, any decision made for a patient who lacks capacity must be made in the patient’s best interests, taking into account their past and present wishes and feelings, beliefs and values. The patient’s preferences may be highlighted by those close to the patient as well as the healthcare team.

Addressing concerns, making decisions

Doctors should proactively seek the preferred medical management of a patient nearing the end of their life, if they have not otherwise objected. Furthermore, doctors have a legal and professional obligation to involve patients and those close to them in “do not attempt cardiopulmonary resuscitation” (DNACPR) decisions (unless this would cause significant harm). In their guidance Treatment and care towards the end of life, the GMC encourages doctors to make sound clinical judgement, explain the clinical issues and support patients and their loved ones during emotional and uncertain times. Doctors are reminded to share information about advance care plans, advance decisions and lasting power of attorney (England and Wales)/welfare attorney (Scotland).

Caring for older patients is a privilege and an important responsibility. The GMC provides a useful summary when considering the care of older patients generally when it states:

“You must give [these] patients… the same quality of care as all other patients. You must treat patients and those close to them with dignity, respect and compassion, especially when they are facing difficult situations and decisions about care. You must respect their privacy and right to confidentiality”.

Dr Greg Dollman is a medical adviser at MDDUS

Link: GMC – Better care for older people