Despite being a collection of holistic assessment tools, the comprehensive geriatric assessment primarily focuses on the social category of age during the assessment and disregards for example gender. This article critically reviews the standardized testing process of the comprehensive geriatric assessment in regard to diversity-sensitivity. I show that the focus on age as social category during the assessment process might potentially hinder positive outcomes for people with diverse backgrounds of older patients in relation to other social categories, such (...) as race, gender or socio-economic background and their influence on the health of the patient as well as the assessment and its outcomes. I suggest that the feminist perspective of intersectionality with its multicategorical approach can enhance the diversity-sensitivity of the comprehensive geriatric assessment, and thus improve the treatment of older patients and their quality of life. By suggesting an intersectional-based approach, this article contributes to debates about justice and diversity in medical philosophy and advocates for the normative value of diversity in geriatric medicine. (shrink)

The development of increasingly intelligent and autonomous technologies will eventually lead to these systems having to face morally problematic situations. This gave rise to the development of artificial morality, an emerging field in artificial intelligence which explores whether and how artificial systems can be furnished with moral capacities. This will have a deep impact on our lives. Yet, the methodological foundations of artificial morality are still sketchy and often far off from possible applications. One important area of application of artificial (...) systems with moral capacities is geriatric care. The goal of this article is to afford the methodological foundations for artificial morality, i.e., for implementing moral capacities in artificial systems in general, and to discuss them with respect to an assistive system in geriatric care which is capable of moral learning. (shrink)

Definition of the problem Enjoyment has not yet played a significant role in ethical approaches to (geriatric) care. Rather, the focus of ethical considerations is often on questions of self-reliance and autonomy. Relevant topics are skills loss issues and how to deal with them. Although it is very important to allow grief in the context of the need for care and of aging, the question remains: in how far could an ethics of enjoyment help to set a (...) further focus on questions of relish. Argumentation and sources Philosophical and theological approaches such as those of Emmanuel Lévinas, Ina Praetorius and Corine Pelluchon show the fundamental importance of corporeality, being nourished and enjoyment. Also, moments of sensual indulgence are valued as meaningful by nursing staff and by persons cared for. These moments can be part of professional care but also happen in situations that go beyond nursing activity in the narrower sense. Moments of enjoyment are interrelated with livability, happiness and health but cannot be fully functionalized. Conclusion An ethics of enjoyment based on these approaches can enrich the perception of care and the theoretical and empirical study of care. This article offers an ethical introduction into the topic and a draft of an ethics of enjoyment in theses. (shrink)

The development of health sciences along with the continuous technological progress contribute to the emergence of web applications. There exist many applications supporting the work of doctors, whereas the market definitely lacks solutions supporting the work of nurses. This is particularly evident in long-term geriatric home care, in which the nursing specialization is developing rapidly. Care of elderly patients requires the nurse to collect medical documents from each visit. Considering the large number of diseases affecting elderly people (...) and the number of required visits – which should exceed 4 a week – a decision was made to develop an Internet application supporting the work of nurses in long-term geriatric care. The application facilitates the process of geriatric patient description in order to eliminate the need for filling in paper medical records. This study presents the method of developing an Internet application supporting the work of nurses in long-term geriatric care. The software was developed based on an analysis of conclusions from a social study carried out in a group of 42 nurses providing geriatric long-term home medical care services in the district of Białystok, Poland. The aim of the study was to determine the features, functionality, and declarative interest in using the software. Conclusions from the analysis indicated that the attempt to develop the application had been justified. Moreover, conclusions from the social survey formed the basis for formulating the design assumptions. The web application was developed in the following technologies: HTML 5, CSS3, JavaScript, PHP 7, and MySQL. First, a prototype of the solution was tested in a XAMPP environment. After successful tests, the app was tested in a nursing practice. The obtained test results raise high hopes for potential commercialization of the application. (shrink)

The aim of this study was to obtain an increased understanding of the experiences of elderly people in geriatric care, with special reference to integrity. Data were collected through qualitative interviews with elderly people and, in order to obtain a description of caregivers’ integrity-promoting or non-promoting behaviours, participant observations and qualitative interviews with nursing students were undertaken. Earlier studies on the integrity of elderly people mainly concentrated on their personal and territorial space, so Kihlgren and Thorsén opened up (...) the possibility of considering the concept of integrity from a broader view by recognizing its relationship to the larger framework of the self-concept. Based on this, findings in the present study indicate that elderly people’s integrity relating to their corporal self were the least violated. On the other hand, their psycological, information and cultural selves were the most exposed. The study also identified a further dimension (i.e. one relating to social self), which should be included in the concept of integrity because respecting elderly people’s social self reduces their feelings of loneliness, isolation and seclusion. In summary, the results indicate that the concept of integrity is complex and has several dimensions. (shrink)

Introduction: Empathy is a complex human experience that involves the subjective intersection of different individuals. In the context of nursing care in the geriatric setting, the benefits of empathetic relationships are directly related to the quality of the practice of nursing. Objective: Analyze scientific production on the benefits of empathy in the nurse–patient relationship in the geriatric care setting. Methods: An integrative review of the literature was performed using the PubMed, Cochrane, CINAHL, Scopus, PsycINFO, and Web (...) of Science databases. The articles retrieved were organized, evaluated, and classified based on the level of scientific evidence. Results: Relationships of empathy between nurses and older people were analyzed in quasi-experimental studies using different assessment tools, the majority of which had moderate levels of validity and reliability. Studies with a qualitative approach discussed the meaning of empathy in terms of the quality of care offered, compassion, and vulnerability. Discussion: Levels of empathy increase when activities are developed with the aim of teaching, sensitization, and training for relational care between nursing staff and older people. The analysis of empathetic relationships is important to the evaluation of the quality of care provided to older people. Conclusion: Empathy in the nurse–patient relationship in the geriatric care setting is an important ethical aspect that contributes to the quality of the practice of nursing. The present findings indicate the need for more robust assessment tools with adequate psychometric properties and the descriptive analysis of empathy. (shrink)

Fall prediction using machine learning has become one of the most fruitful and socially relevant applications of computer vision in gerontological research. Since its inception in the early 2000s, this subfield has proliferated into a robust body of research underpinned by various machine learning algorithms (including neural networks, support vector machines, and decision trees) as well as statistical modeling approaches (Markov chains, Gaussian mixture models, and hidden Markov models). Furthermore, some advancements have been translated into commercial and clinical practice, with (...) companies in various stages of development capitalizing on the aging population to develop new commercially available products. Yet despite the marvel of modern machine learning-enabled fall prediction, little research has been conducted to shed light on the security and privacy concerns that such systems pose for older adults. The present study employs an interdisciplinary lens in examining privacy issues associated with machine learning fall prediction and exploring the implications of these models in elderly care and the Internet of Medical Things (IoMT). Ultimately, a justice-informed set of best practices rooted in social geroscience is suggested to help fall prediction researchers and companies continue to advance the field while preserving elderly privacy and autonomy. (shrink)

Physicians, registered nurses and enrolled nurses engaged in geriatric and surgical care at a large hospital in Sweden gave 180 accounts of morally difficult care episodes. In total, the ENs gave 78, the RNs 55 and the physicians 47 accounts; there were 83 from geriatric care and 97 from surgical care. Forty-nine participants were male, and 59 were female; there were no differences in gender in the form and content of the moral reasoning disclosed (...) in either morally difficult care episodes or in the complete interviews when coded as mainly narrative or propositional, or as showing a care or a justice orientation. The ENs showed a care orientation, while RNs and physicians, to an equal degree, showed both a justice and a care orientation. The ENs also used narrative reasoning more often than RNs and physicians. No differences were seen between the two health care specialties. (shrink)

Physicians, registered nurses (RNs) and enrolled nurses (ENs) engaged in geriatric (n = 49) and surgical (n = 59) care at a large hospital in Sweden gave 180 accounts of morally difficult care episodes. In total, the ENs (n = 40) gave 78, the RNs (n = 38) 55 and the physicians (n = 30) 47 accounts; there were 83 from geriatric care and 97 from surgical care. Forty-nine participants were male, and 59 were (...) female; there were no differences in gender in the form and content of the moral reasoning disclosed in either morally difficult care episodes or in the complete interviews when coded as mainly narrative or propositional, or as showing a care or a justice orientation. The ENs showed a care orientation, while RNs and physicians, to an equal degree, showed both a justice and a care orientation. The ENs also used narrative reasoning more often than RNs and physicians. No differences were seen between the two health care specialties. (shrink)

Today many adult children find themselves in the position of caring for elderly parents and attending to the other demands of life. Because of the unique balance of power in the adult child/elderly parent relationship as well as other negative influences, many adult children find caring for parents a frustrating task. This article argues a solution to this dilemma can be found in a renewed appreciation of filial piety as it specifically relates to caring for elderly parents. Using the moral (...) insights of Aristotle and Aquinas, this paper develops a contemporary theoretical framework for geriatric filial piety that incorporates the traditional virtues of gratitude, respect, honor and obedience. It also illustrates their practical application so that adult children can find caring for their elderly parents a meaningful activity. (shrink)

How can we provide the best care for the growing population of older adults, many of whom are either very frail or very sick? The traditional medical model of care is focused on treatment of single diseases. This can work well for pneumonia, cancer, or diabetes in younger patients. It does not, however, work as well for frail older adults who have accumulated multiple chronic conditions and disabilities. These elders often depend on family or paid caregivers to provide (...) assistance with taking medications, transportation, and other activities of daily living, such as dressing and bathing. A practitioner in the traditional medical model might prescribe medications that make sense in isolation but have harmful... (shrink)

This paper discusses the role that the personal history plays in a patient’s perception of his or her own illness in the light of the patient’s own personal history. It demonstrates the regrettable modern tendency to regards the patient as the “bearer of a disease” rather than as a human being with personal values and experiences into which their current illness needs to be integrated. I illustrate my point by an exchange between a student and an “attending” and the “attending” (...) and the patient. It represents only one out of unfortunately many such instances in which the pressures of “managed care” and “efficiency” have made truly knowing the patient as an individual with life experiences and personal values much more difficult. (shrink)

We wish to extend the concepts in Ray and Cooper’s (2024) article entitled “The Bioethics of Environmental Injustice: Ethical, Legal, and Clinical Implications of Unhealthy Environments” to palliat...

The increasing incidence of ethical dilemmas in long-term care settings, in concert with recommendations from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, has prompted long-term care institutions to develop mechanisms to address these concerns. Some facilities have chosen to set up an ethics committee, although estimates obtained in the past few years indicate that only between 2 and 27% of institutional long-term care settings have such committees. Ethics committees (...) are responsible for assisting staff, residents, and families with the resolution of ethi- cal concerns, and typically engage in policy review and development, case review, and education. Such committees usually count among their membership representatives from a variety of disciplines, with family members, patients, and representatives from patient advocacy groups supplementing the professional component of the committee. (shrink)

It is commonly believed thatgeriatric medicine generates a distinctive setof ethical problems. Implicated are such issuesas resource allocation, competence and consent,advance directives, medical futility anddeliberate death. It is also argued that itwould be unjust to allow the elderly to competewith younger populations for expensive andscarce health care resources because theelderly “have already lived,” and that treatingthem the same as these other populations woulddiminish the available resources unfairly,prolong a life of inevitably failing health andresult in increased health care expenditures.In (...) fact, however, this perception of ethicaluniqueness is mistaken. Differences in medicalconditions, demographics and aetiology shouldnot be allowed to obscure the fact that ethicalissues in geriatric medicine are essentiallythe same as those faced in any other area ofhealth care, and that the solutions that areadopted in the geriatric context must beconsistent with the ethical principles that arefollowed elsewhere. The paper argues that theroot of the mistaken perception lies in theabandonment of the Hippocratic mandate ofmedicine and in an unreflective adherence tothe belief that medical advances are inevitablybeneficial. It is suggested that a return topatient-centred medicine and the use of ethicsimpact analyses before introducing medicaladvances may be ethically appropriate. (shrink)

Respecting and encouraging autonomy in the elderly is basic to the practice of geriatrics. In this paper, we examine the practice of cardiopulmonary resuscitation (CPR) and "artificial" feeding in a geriatric unit in a general hospital subscribing to jewish orthodox religious principles, in which the sanctity of life is a fundamental ethical guideline. The literature on the administration of food and water in terminal stages of illness, including dementia, still shows division of opinion on the morality of withdrawing nutrition. (...) We uphold the principle that as long as feeding by naso-gastric (N-G) or percutaneous endoscopic gastrostomy (PEG) does not constitute undue danger or arouse serious opposition it should be given, without causing suffering to the patient. This is part of basic care, and the doctor has no mandate to withdraw this. The question of CPR still shows much discrepancy regarding elderly patients' wishes, and doctors' opinions about its worthwhileness, although up to 10 percent survive. Our geriatric patients rarely discuss the subject, but it is openly ventilated with families who ask about it, who are then involved in the decision-making, and the decision about CPR or "do-not-resuscitate" (DNR) is based on clinical and prognostic considerations. (shrink)

Modern mainstream ethical theories with its overemphasis on autonomy and non-interference have failed to adequately respond to contemporary social problems. A new ethical perspective is very much needed. Thanks to Carol Gilligan's 1982 groundbreaking work, 'In a Different Voice' , we now not only have virtue and communitarian ethicists, but also a group of feminist philosophers, charting a new direction for ethics that tempers modern ethics' obsession with autonomy, contractual rights, and abstract rules. Nel Noddings, in her 'Caring: A Feminine (...) Approach to Ethics and Moral Education', further contributed to this important discussion. In this work, Noddings proposes a new kind of moral ideal. She calls it "caring." Noddings defines "caring," as a direct, felt concern and action from the one-caring toward the well-being of the cared-for. In other words, care is a state of mental engrossment and motivational displacement that impels caring actions for the happiness of the cared-for and it transcends any rule-bound moral judgment. A caring attitude is best manifest in the spontaneous emotive bond of love between a mother and a child. This human relation of unscrutinized maternal love and care should be the model of ethics. Noddings's theory evokes a vigorous debate concerning whether or not the model can withstand rigorous philosophical scrutiny as a stand-alone ethical theory. This paper first discusses the strengths and weaknesses of a pure care ethics. Secondly, it demonstrates why both the Kantian and the Aristotelian attempts are unsatisfactory, and it offers a Confucian solution to the problems of care ethics. It argues that notwithstanding gender-oppressive practices that are at times associated with Confucianism, Confucian ethics of 'ren' (humaneness) is both more compatible with care ethics and is better equipped with conceptual resources than Kantian liberalism or Aristotelian virtue ethics to handle the moral predicament of the postmodern world. The paper demonstrates that care is an inherent element of Confucian 'ren' but that 'ren' is more than Noddings's care. It examines three essential principles that can be extracted from philosophical classical Confucianism: (1) an affectionate and particularistic approach to persons, (2) the mutual conditioning of the two prominent Confucian virtues -- humaneness (ren) and ritual propriety (li), and (3) the inseparability of the familial and the political self. The last section of the paper applies Confucian care ethics to concrete cases such as the geriatric care crisis and the problem of poverty. (shrink)

This essay looks to the omission of aging queer bodies from new medical technologies of sex. We extend the Foucauldian space of the clinic to the mediascape, a space not only of representations but where the imagination is conditioned and different worlds dreamed into being. We specifically examine the relationship between aging queers and the marketing of technologies of sexual function. We highlight the ways queers are excluded from the spaces of the clinic, specifically the heternormative sexual scripts that organize (...) biomedical care. Finally, using recent zombie theory, we gesture toward both the constraints and possibilities of queer inclusion within the discourses and practices that aim to reanimate sexual function. We suggest that zombies usefully frame extant articulations of aging queers with sex and the dangerous lure of medical treatments that promise revitalized, but normative, sexual function at the cost of other, perhaps queerer intimacies. (shrink)

Caregiving robots are often lauded for their potential to assist with geriatric care. While seniors can be wise and mature, possessing valuable life experience, they can also present a variety of ethical challenges, from prevalence of racism and sexism, to troubled relationships, histories of abusive behavior, and aggression, mood swings and impulsive behavior associated with cognitive decline. I draw on Confucian ethics, especially the concept of filial piety, to address these issues. Confucian scholars have developed a rich set (...) of theoretical resources for dealing with beloved but imperfect elders, and navigating the challenges of supporting seniors whose ethical commitments are unreliable. These resources provide a way to reconcile two important but conflicting desiderata: to value and care for seniors, but also to clear-mindedly deal with their moral shortcomings. In particular, they articulate a duty to remonstrate with our elders when they err. Confucian filial piety can helpfully inform robot design and use in geriatric care. They can be used to strengthen and protect emotional connections in important relationships, but should not be used to reinforce patient preferences when doing so damages relationships or their ability to act morally. Rather than conceive of patient wellbeing as in tension with moral behavior, and care as a burden for caregivers, not a source of value and meaning, Confucian accounts of filial piety help identify both new areas of concern and new potential in the development of caregiving technologies, ones which see these goods as complementary. (shrink)

As the world population is rapidly aging, stakeholders must address the care of the elderly with great concern. Also, loss of dignity is often associated with aging due to dementia, mobility problems and diminished functional autonomy. However, dignity is a polysemic term that is deemed useless by some ethicists. To counter this claim, we propose four concepts to define it better and make use accurately of this notion. These are human dignity, dignity of identity, dignities of excellence and attributed (...) dignities. Finally, we explain the importance of solicitude and human dignity in the care of the elderly. This will ensure the respect, friendship and dignity of the elderly in providing geriatric ethical care. (shrink)

It has become common in medical ethics to discuss difficult cases in terms of the principles of respect for autonomy, beneficence, nonmaleficence, and justice. These moral concepts or principles serve as maxims that are suggestive of appropriate clinical behavior. Because this language evolved primarily in the acute care setting, I consider whether it is in need of supplementation in order to be useful in the long-term care setting. Through analysis of two typical cases involving residents of long-term (...) class='Hi'>care facilities, I argue for the additional principles of candor and responsibility for narrative integrity. (shrink)

Immediately following the approval of the Belgian law on euthanasia, Caritas Catholica Vlaanderen sent a position paper to all affiliated institutions in which its standpoint regarding care for a dignified end of life is clarified. We would like to sketch very briefly the context in which this position paper should be placed, before reproducing the complete text of the recommendation.Caritas Catholica Vlaanderen is an umbrella organization for cooperation and consultation between the Verbond der Verzorgingsinstellingen [Association of Care Institutions], (...) grouping health-care institutions and services, and the Vlaams Welzijnsverbond [Flemish Association for Public Welfare], grouping welfare institutions and services. The Verbond der Verzorgingsinstellingen is responsible for 52 general hospitals, 94 mental-health institutions and 326 geriatric-care institutions. The Vlaams Welzijnsverbond groups 397 facilities for handicapped persons and 344 facilities for public welfare. (shrink)

New technologies such as smart sensors improve rehabilitation processes and thereby increase older adults’ capabilities to participate in social life, leading to direct physical and mental health benefits. Wearable smart sensors for home use have the additional advantage of monitoring day-to-day activities and thereby identifying rehabilitation progress and needs. However, identifying and selecting rehabilitation priorities is ethically challenging because physicians, therapists, and caregivers may impose their own personal values leading to paternalism. Therefore, we develop a discussion template consisting of a (...) series of adaptable questions for the patient–physician encounter based on the capability approach. The goal is to improve geriatric rehabilitation and thereby increase participation in social life and well-being. To achieve this goal, we first analyzed what is considered important for participation on basis of the capability approach, human rights, and ethics of care. Second, we conducted an ethical analysis of each of the four identified dimensions of participation: political, economic, socio-cultural, and care. To improve compliance with rehabilitation measures, health professionals must align rehabilitation measures in an open dialogue with the patient’s aspiration for participation in each dimension. A discussion template based on the capability approach allows for a proactive approach in patient information and stimulates a critical assessment of treatment alternatives while reducing the risk of imposing personal values. (shrink)

The purpose of this study is to determine empirically the state of the art of the medical care, when healthcare personal is confronted with ethical dilemmas related with the care they give to the geriatric population. An observational, longitudinal, prospective and qualitative study was conducted by analyzing the correlation between healthcare personnel–patient relationship, and ethical judgments regarding dilemmas that arise in daily clinical practice with geriatric patients. Mexican healthcare personnel with current active practices were asked to (...) write up an ethical dilemma that arose frequently or that had impacted their medical practice. From the narrative input, we were able to draw up a database with 421 dilemmas, and those corresponding to patients 60 years and older were selected. The axiological analysis of the narrative dilemmas of geriatric patients was made using dialectical empiricism. The axiological analysis values found most frequently were classified into three groups: the impact of healthcare, the roles of the physician, and refusal of therapy; the healthcare role of educator, caring for the patients’ life and the risk of imminent death where the values found more often. The persistence and universality of certain dilemmas in geriatrics calls for awareness and requires a good training in the ethical discernment of these dilemmas. This would help to improve substantially the care and the life quality of this population. (shrink)

Background: Neglect and abuse of elders in care institutions is a recurring issue in the media. Elders in care institutions are vulnerable due to their physical, cognitive, and verbal limitations. Such vulnerabilities may make them more susceptible to mistreatment by caregivers on whom they are heavily dependent. Objectives: The goal was to understand caregivers’ concerns about ensuring correct and proper treatment, as well as their experiences with neglect and abuse of older patients. This article examines resources and challenges (...) of professional ethics within the care setting. Research design: A study was conducted to explore the quality of care provided to older patients in nursing homes, geriatrics institutions, and ambulant care in the northwest region of Switzerland. Participants and research context: A total of 23 semi-structured interviews were conducted with nursing staff of varying experience levels. Ethical considerations: Ethical approval was granted by the competent regional ethics commission, Ethikkomission Nordwest-und Zentralschweiz EKNZ [Ethics Commission Northwest and Central Switzerland]. Findings: Three themes emerged from our data analysis: professional identity, professional context, and professional relationships. Our findings indicate mutual vulnerabilities within these three themes, characterizing the interactions between nursing staff and older patients. Study participants believe that incidences of error, neglect, and abuse are consequences of their own vulnerability since they are not able to meet the demands of an overstraining work situation. Discussion: Different aspects of this mutual vulnerability are described and critically discussed as challenges for professional ethics. Conclusion: Early education, continuous training as well as better management and response from the institution are necessary to maintain professionalism while handling mutual vulnerabilities. (shrink)

Patient portals are poised to transform health communication by empowering patients with rapid access to their own health data. The 21st Century Cures Act is a US federal law that, among other provisions, prevents health entities from engaging in practices that disrupt the exchange of electronic health information—a measure that may increase the usage of patient health portals. Caregiver access to patient portals, however, may lead to breaches in patient privacy and confidentiality if not managed properly through proxy accounts. We (...) present an ethical framework that guides policy and clinical workflow development for healthcare institutions to support the best use of patient portals. Caregivers are vital members of the care team and should be supported through novel forms of health information technology (IT). Patients, however, may not want all information to be shared with their proxies so healthcare institutions must support the development and use of separate proxy accounts as opposed to using the patient’s own account as well provide controls for limiting the scope of information displayed in the proxy accounts. Lastly, as socioeconomic barriers to adoption of health IT persist, healthcare providers must work to ensure multiple streams of patient communication, to prevent further propagating health inequities. (shrink)

This volume explains why, and in what ways, health care is being rationed in the late-1990s health service. It examines the ethical questions which arise from this rationing and includes personal case studies, from surgeons to geriatric advisors.

Health professionals increasingly face patients with complex health problems and this pressurizes them to cooperate. The authors have analyzed how the complexity of health care problems relates to two types of cooperation: consultation and multidisciplinary teamwork (MTW). Moreover, they have analyzed the impact of these two types of cooperation on perceived professional autonomy. Two teams were studied, one team dealing with geriatric patients and another treating oncology patients. The authors conducted semi-structured interviews, studied written documents, held informal discussions (...) and observed the teams at work. Consultation was most likely to take place when a patient had multiple problems. However, if these problems were interrelated, i.e. the solution for one problem interfered with solving another, then MTW was favored. The same was true when the available information was equivocal such that there were conflicting interpretations of a problem. How the professionals perceived the relationship between complexity and the need to cooperate depended on their expertise, their occupational background, and their work orientation. Consultation did not affect the professional autonomy of the health care professionals. MTW however did decrease the perceived level of professional autonomy. The extent to which this occurred seemed to depend on the quality of the interpersonal relations within the team. The findings can help in selecting the most appropriate and efficient type of cooperation based on the complexity of a patient’s problems. They can also help team leaders to stimulate reflection and feedback processes, and medical trainers to develop competencies among students related to such teamwork behaviors. (shrink)

In the state of Victoria, Australia in the late 1950s and early 1960s, restorative treatment was introduced into the state‐subsidised benevolent homes, and they were reclassified as geriatric hospitals. In the process, the nursing care of incapacitated old people was identified in terms of particular skills and knowledge, and specific forms of training were established for nurses at two levels of training: nurses’ aides and supervisory nurses with a postbasic qualification. These institutional changes were complemented by the introduction (...) of a nursing role into the body responsible for overseeing care for the aged in Victoria. Little was made of this opportunity to establish a leading role for nurses in the field of care for the aged. However, this episode raises fertile questions for further research into the development of nursing in Australia, as a set of practices divided along the lines of acute and chronic illness. (shrink)

In recent years, experts in geriatric care have increasingly promoted the use of reminiscence museums, collections of period objects that are used to help senior citizens draw on old memories in order to recall and talk about their past. Hands Off Not an Option is a practical guide to making and using such collections, showing how to establish and fill out a museum and illustrating the ways it can be used within senior care facilities and within individual (...) homes. The book will thus be of value both to those practicing in geriatric medical and social care and to individual families working with aged relatives. The book includes 1 DVD. (shrink)

Workplace learning and competence development in work are frequently used concepts. A wide spread notion is that societal, institutional, and organizational changes require the development of knowledge, methods and strategies for learning at workplaces, in both public and private enterprises. In research on learning and competence development at work, the organizational learning and development as well as individual accomplishments are investigated from various perspectives and in different contexts. The theoretical base for research projects can, accordingly, be focused at a number (...) of organizational and system levels. This paper describes a research project called "Workplace development and learning in elder care" in which learning and knowledge were key issues and where Activity Theory was used as the theoretical base. The project was joint project between two research and development field units. These were UFFE, a municipal social services’ field research unit, and Äldrecentrum Västerbotten, a county council field research unit which aims to serve the interests of the elderly. The project was launched in the fall of 2000 and ended in the summer of 2003. I was employed part-time as a research leader at the municipal research unit and became the research leader for this particular project. A number of students, as well as employees from the county council geriatric care services and the municipal elder care participated in the project. The general aims of the project were to: a) investigate the prerequisites for development and learning; b) test and evaluate interventions at a workgroup level; and c) identify the need for new knowledge. The results were expected to be useful for the field research units as well as for the municipal and county eldercare services in their research and development work. I start with a presentation of the theoretical concepts and apply them in order to form a tentative hypothesis on the status of learning and knowledge in elder care. The next section contains a short description of the different parts of the project and the main results are presented. Finally, the results are discussed and related to the conditions and impact of workplace interventions. (shrink)

Background Thirst and dry mouth are common symptoms in terminally ill patients. In their day-to-day practice, palliative care physicians regularly encounter ethical dilemmas, especially regarding artificial hydration. Few studies have focused on thirst and the ethical dilemmas palliative care physicians encounter in relation to this, leading to a knowledge gap in this area. Aim The aim of this study was to explore palliative care physicians’ experiences of ethical challenges in relation to thirst in terminally ill patients. Methods (...) A qualitative interview study with an inductive approach was conducted. Sixteen physicians working in four different specialised palliative care units and one geriatric care unit in different hospitals in Sweden were interviewed. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis. Results When presented with an ethical challenge relating to thirst, physicians attempted to balance benefits and harms while emphasizing respect for the patient’s autonomy. The ethical challenges in this study were: Starting, continuing or discontinuing drips; lack of evidence and traditions create doubt; and lack of interest and time may result in patient suffering. Conclusions All physicians in this study reported that “Starting, continuing or discontinuing drips” was the main ethical challenge they encountered, where some were so accustomed to the decision that they had a standard answer ready to offer patients and families. Physicians reported that drips were a symbol of thirst quenching, life and survival but were not necessary in end-of-life care. Others questioned the traditions regarding thirst and emphasised drips in particular. (shrink)

The development of increasingly intelligent and autonomous technologies will eventually lead to these systems having to face morally problematic situations. This is particularly true of artificial systems that are used in geriatric care environments. The goal of this article is to describe how one can approach the design of an elder care robot which is capable of moral decision-making and moral learning. A conceptual design for the development of such a system is provided and the steps that (...) are necessary to implement it are described. (shrink)

This study aimed to describe and compare the views of nurses and older patients' relatives on factors restricting the maintenance of patient integrity in long-term care. The purposive sample comprised 222 nurses and 213 relatives of older patients in four Finnish long-term care institutions. The data were collected using a self-developed questionnaire addressing five sets of factors relating to patients, relatives, nurses, the organization and society. The maintenance of patient integrity was restricted by: (1) social factors, including lack (...) of respect for long-term geriatric care and lack of adequate resources; (2) patient factors relating to forgetfulness; and (3) factors relating to nurses and relatives in maintaining patient integrity. Better maintenance of patient integrity requires that more consideration is paid to issues of social respect and to the availability of adequate resources. Closer attention must be given to patients who are forgetful and unable to take part in decision making. (shrink)

The expansion of the older population suggests that there will be significant numbers in need of care and support in their own home environment. Yet, little is known about the kind of situations professionals are faced with and how they intervene in the living environment of older people. Qualitative data were collected over a period of 1.5 years from a multi-disciplinary community-based geriatric team in the Netherlands, and participant observations carried out. Forty-two cases discussed within the team meetings (...) were analysed. Results demonstrate that providing care to older people is a dynamic process and revolves around various paradoxes as experienced by professionals. This is illustrated by presenting three paradoxes that emerged within the data: respecting autonomy versus preserving safety; the care needs of the care recipients versus the capacity of their informal carers to cope; and holding a formal orientation versus a tailored orientation on tasks. Providing care in the home environment of older people requires from professionals a continuous anticipation of (un)expected evolutions in situations of their care recipients. In order to optimally support older people professionals need ‘professional discretion’. They must be supported to systematically reflect on and legitimize their intervention strategies. (shrink)

In his paper, which we read with interest, Cherniack argues that there is a worldwide increase in the use of do not resuscitate orders in the care of the elderly.1 As geriatricians in an emergency department and a geriatric department we are concerned by this important ethical topic, and we understand that this increase is a reflection of the demographic increase in frail very old persons. The elderly must be offered the best care, and age as such (...) should not be used as a decision criterion in order to exclude them from the best care. Nevertheless, care which is believed to be harmful and treatments which are considered futile must not be offered, and in some circumstances must not even be discussed. In the setting of the care of the frail elderly, we believe the use of simple DNR orders to be inappropriate and restrictive, because they fail to outline the kind of care and the extent of the care that the patient actually needs. We prefer a more nuanced approach based on a scale describing positively the contents of care at four different levels: terminal, palliative, usual, and intensive, only the last to include cardiopulmonary resuscitation . Perhaps a more …. (shrink)

Not long after matriculation—sometimes even before—medical students begin hearing the question, "So, what are you going into?" It can be heard as a colloquial version of a practical question, "To which type of residency are you planning to apply?" Some will evade the question, claiming, perhaps sincerely, to be fascinated by everything from radiology to geriatrics, open to all possible paths. Others will acknowledge that they enjoy or dread working with children, that they crave long-term relationships or bursts of adrenaline, (...) that they are drawn to the knife or sickened at the sight of blood. A smaller number will confess to having a clear vision of their futures, perhaps a desire to... (shrink)

The paper discusses inappropriate (futile) treatment by analyzing the casuistics of palliative patients in the terminal stage of illness who are hospitalized at the Department of Internal Medicine and Geriatrics of the Faculty hospital with policlinic (FNsP). Our research applies the principles of palliative care in the context of bioethics. The existing clinical conditions of healthcare in Slovakia are characteristic of making a taboo of the issues of inappropriate treatment of palliative patients. Inductive-deductive and normative clinical bioethics methods of (...) palliative care and ethical strategy are applied for defining issues found in inappropriate hemodialysis treatment. An algorithm of hemodialysis treatment requires the definition of those lege artis criteria which, in the context of a patient’s autonomy and his/her decision, precondition the avoidance of the situation in which hemodialysis treatment is inappropriate (futile). Futile treatment in a terminal condition is ethically inappropriate medical treatment that extends the suffering of patients and their relatives. Its definition is determined by the relevant legislation and the methods of bioethics. An active palliative strategy is aimed at managing the process of incurable diseases in the patient’s bio-psycho-socio-spiritual continuity in the process of special bioethics. The global bioethical objective of general bioethics for palliative care is based on the paradigm of social harmony and solidarity in the context of an authentic modus of the patient’s existence as a constitutive principle for the phenomenon of the patient’s being to finite being (death). (shrink)

Diagnosis of dementia in primary care is both difficult and important. The recommendations by several authors to improve the diagnosis of dementia by general practitioners are important, but insufficient. It is argued that perhaps the disease concept in itself is a cause of confusion for clinicians. Primary care physicians need an adapted procedure, gradually leading to the final diagnosis of dementia. It has to be a stepwise labelling strategy, using global descriptions and non-disease specific labels in the beginning, (...) ending up with well-defined disease criteria. In this process, there is circularity: previous diagnoses have to be kept in mind because symptoms and signs may gradually change during the progression of the disease, leading to reconsideration of previous deleted options. To frame this properly, the primary care physician needs to adopt a broad frail elderly geriatric concept. Implementation of this concept not only helps the diagnostic process, but also stimulates the care for dementing patients and their caregivers. Relevant arguments for early diagnostic involvement of primary care physicians can be put forward on condition that a new concept, adapted procedures and adapted instruments are used. (shrink)

In their practice, nurses make daily decisions that are ethically informed. An ethical decision is the result of a complex reasoning process based on knowledge and experience and driven by ethical values. Especially in acute elderly care and more specifically decisions concerning the use of physical restraint require a thoughtful deliberation of the different values at stake. Qualitative evidence concerning nurses’ decision-making in cases of physical restraint provided important insights in the complexity of decision-making as a trajectory. However a (...) nuanced and refined understanding of the reasoning process in terms of ethical values is still lacking. A qualitative interview design, inspired by the Grounded Theory approach, was carried out to explore nurses’ reasoning process in terms of ethical values. We interviewed 21 acute geriatric nurses from 12 hospitals in different regions in Flanders, Belgium in the period October 2009–April 2011. The Qualitative Analysis Guide of Leuven was used to analyse interview data. Nurses’ decision-making is characterized as an ethical deliberation process where different values are identified and where the process of balancing these values forms the essence of ethical deliberation. Ethical decision-making in cases of physical restraint implies that nurses have to choose which values receive priority in the process, which entails that not all values can be respected to the same degree. As a result, decision making can be experienced as difficult, even as a dilemma. Driven by the overwhelming goal of protecting physical integrity, nurses took into account the values of dignity and justice more implicitly and less dominantly. (shrink)

The cost-effectiveness of 24-hour care makes it a major source of support for elderly people in need of home-based care in Austria. Language barriers, feelings of isolation when living with chronically ill people and a lack of adequate training and quality control create stressful working conditions for 24-hour caregivers in Austria, who mainly come from Slovakia, Hungary and Romania. The challenges not only affect the 24-hour caregivers themselves but also their clients, relatives and registered care agency nurses (...) in care settings. The aim of the qualitative study was to assess user needs in order to develop an app to improve working conditions and quality assurance in 24-hour home-care. The study consisted of guided interviews, focus group and cultural probes and 45 interviewees. The collected data were analyzed using Kuckartz’s method of content structuring qualitative content analysis. The main results show that 24-hour caregivers predominantly require information about common geriatric diseases and the law on 24-hour care. Additionally, medical emergencies can cause insecurities, which creates high interest in professional emergency management skills. Clients and relatives are especially interested in 24-hour caregivers having better German language skills. Care agencies and registered nurses would particularly welcome electronic care documentation to ensure traceability of the activities and measures taken. The study points to the need for a digital tool that would meet demand for an appropriate assistance system for 24-hour home-care that complies with the AAL requirements of the aligned project. Therefore, the intended software solution meets challenges in 24-hour home-care for 24-hour caregivers, persons in need of care, their relatives and professionals involved in the 24-hour care setting. (shrink)

Physicians and families need to interact more meaningfully to clarify the values and preferences at stake in advance care planning. The current use of advance directives fails to respect patient autonomy. This paper proposes using the family covenant as a preventive ethics process designed to improve end-of-life planning by incorporating other family members—as agreed to by the patient and those family members—into the medical care dialogue. The family covenant formulates advance directives in conversation with family members and with (...) the assistance of a physician, thereby making advance directives more acceptable to the family, and more intelligible to other physicians. It adds the moral force of a promise to the obligation of respecting a patient’s preferences about end-of-life care. These negotiations between patient, family, and physician, from early planning phases through implementation, should greatly reduce the incidence of family disagreements on what the patient would have wanted. The family covenant ensures advance directive discussions within the family, promotes and respects the autonomy of other family members, and might even spur others in the family to complete advance directives through additional covenants. The family covenant holds the potential to transform moral quagmires into meaningful moral conversation. J Am Geriatr Soc 51:1155–1158, 2003. (shrink)

RationaleSurrogates of critically ill patients often have inaccurate expectations about prognosis. Yet there is little research on how intensive care unit clinicians should discuss prognosis, and existing expert opinion-based recommendations give only general guidance that has not been validated with surrogate decision makers.ObjectiveTo determine the perspectives of key stakeholders regarding how prognostic information should be conveyed in critical illness.MethodsThis was a multicenter study at three academic medical centers in California, Pennsylvania, and Washington. One hundred eighteen key stakeholders completed in-depth (...) semistructured interviews. Participants included 47 surrogates of adult patients with acute respiratory distress syndrome; 45 clinicians working in study ICUs, including physicians, nurses, social workers, and spiritual care providers; and 26 experts in health communication, decision science, ethics, family-centered care, geriatrics, healthcare disparities, palliative care, psychology, psychiatry, and critical care.Measurements and main resultsThere was broad support among surrogates for existing expert recommendations, including truthful prognostic disclosure, emotional support, tailoring the disclosure strategy to each family's needs, and checking for understanding. In addition, stakeholders offered suggestions that add specificity to existing recommendations, including: In addition to conveying prognostic estimates, clinicians should help families "see the prognosis for themselves" by showing families radiographic images and explaining the clinical significance of physical manifestations of severe disease at the bedside. Many physicians did not support using numeric estimates to convey prognosis to families, whereas many surrogates, clinicians from other disciplines, and experts believed numbers could be helpful. Clinicians should conceptualize prognostic communication as an iterative process that begins with a preliminary mention of the possibility of death early in the ICU stay and becomes more detailed as the clinical situation develops. Although prognostic information should be initially disclosed by physicians, other members of the multidisciplinary team-nurses, social workers, and spiritual care providers-should be given explicit role responsibilities to reinforce physicians' prognostications and help families process a poor prognosis emotionally.ConclusionsFamily members, clinicians, and experts identified specific communication behaviors that clinicians should use to discuss prognosis in the critical care setting. These findings extend existing opinion-based recommendations and should guide interventions to improve communication about prognosis in ICUs. (shrink)