Care of older people: Maintaining the dignity and autonomy of older people in the healthcare setting

Insensitivity and disrespect

Health services should aim to preserve dignity and autonomy and minimise distress among patients. 2 3 Yet the literature suggests that, in many cases, these objectives are not being reached. Although the empirical evidence on dignity is limited, many valuable qualitative data are available. Surveys conducted primarily by older people's advocacy groups have directly obtained the views and experiences of older service users and their carers.4^–7 They show an alarming picture of older people being treated unacceptably—insensitively and disrespectfully—by healthcare staff (see box for examples).

Owing to the anecdotal nature of the data, it is difficult to assess how widespread such bad practice is. The international authorship, however, of articles on older people's dignity and autonomy in health care suggests that difficulties in maintaining high standards may be a global problem.9^–12

Although interrelated, dignity and autonomy are slightly different concepts. Dignity refers to an individual maintaining self respect and being valued by others. Autonomy refers to individual control of decision making and other activities. The literature suggests that both the dignity and the autonomy of older people are often undermined in healthcare settings. Dignity is challenged primarily through negative interactions between staff and patients, a lack of regard for patients' privacy, and a general insensitivity to the needs and desires of an older population.4^–6 Autonomy is threatened when patients (and their carers) are not given adequate information or the opportunity to understand fully their diagnosis and to make informed choices about their care. 7 13^–15 Older people in particular easily become disempowered in healthcare settings.16

Raising standards

How can standards in geriatric health care be raised? One way is to examine the examples of good practice that exist and identify elements that can be generalised to health services globally. Much of the qualitative information already mentioned, along with several documents focusing specifically on good practice, reports positive comments made by older people and their carers about care received (see box). Such comments shed light on elements of service provision that allow older people to feel that they are retaining their dignity and autonomy. The feedback shows that information provision and the quality of interactions between staff and patients are key issues. They are key, too, in the findings of research into good practice in acute hospitals in England.18

Tackling negative attitudes through training

The qualitative data cited in this article suggest that attitudes of staff greatly affect both the quality of treatment of older people and the regard given to maintaining their dignity and autonomy. This is a concept well supported by scientific literature: “A nurse's pessimistic viewpoint can translate into a loss of dignity, identity and decision-making power for seniors.”9 And indeed, the evidence suggests that a considerable proportion of medical professionals hold pessimistic views of older people. A survey of nurses and students working with older people in the clinical setting concluded that the sample “expressed stereotypical views about old people in general.”19 Such findings are supported by the recent report by the UK Health Advisory Service: “We did encounter examples of prejudiced attitudes towards older people and their care at almost every level of the service system.”1 Researchers conducting literature reviews have reached similar conclusions.20 Alarmingly, some research has suggested that many professionals hold more ageist attitudes than the general population.21

The literature shows that a key means of tackling poor attitudes by staff towards older people is through extensive and continued training. One study reported that more positive attitudes towards older people were found among nurses working in elderly care than among those working in acute care (which covers all ages) and attributed this to a more specialised training in gerontology.22 Swedish researchers reported that after a year of special education, medical trainees came to view older people with dementia as “unique human beings” rather than “a homogeneous group.”23 Another study reported more favourable attitudes towards the care of older people among students attached to a geriatric ward than among those attached to a general ward.24 It seems, then, that training in geriatrics has a positive effect on the attitudes of staff. In fact, the evidence shows that mere exposure to certain groups of older people is beneficial. Older students and those with grandparents as role models have been found to have better attitudes towards older people.25 Indeed, several authors have written about the importance of healthcare staff being exposed to older people who are healthy as well as to those who are patients. 9 19 Increased and improved training and exposure to older people is also likely to do much to raise the status of geriatrics.24 Improved status is likely to have a positive impact on attitudes and encourage more individuals into the field,26 which in turn will benefit older patients.27

Currently there is a “hotch-potch of training and qualifications,”28 with many staff having received no specific training in the needs and care of older people.1 Such training should be mandatory for all health service staff—not limited to those who work only with older people.29 Staff who are trained and experienced in geriatrics will be not only better equipped to treat older patients but also more sensitive to issues surrounding an older person's dignity and autonomy.

Information provision

Older people and their carers need to be given adequate information to enable them to make informed choices about care. This is necessary at every stage of treatment, including “end of life” care. 30 31 The literature recognises that effective communication and information provision are fundamental principles of quality health care 15 32 33 but also highlights that these principles are often neglected. 7^–13 34 35 The autonomy of older people (and their carers) from ethnic minority groups is further threatened by the fact that medical practitioners are often unaware of cultural sensitivities,36^–38 and information is rarely available in these patients' mother tongue. 39 40 Documents on good practice suggest that when such barriers are overcome, the benefits are plentiful.41 If patients' autonomy is to be maintained, information should be readily available in appropriate formats or languages, be provided in a supportive and sensitive manner, and be reinforced by staff throughout treatment or care.