British Geriatrics Society Newsletter Mar 2007

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The human rights of older people in healthcare
- a call for evidence

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The BGS recently responded to the most recent debate on the human rights of older people in a healthcare context, launched by the UK Parliament Joint Committee on Human Rights.

Despite many old people getting imaginative and appropriate care in hospitals the BGS has responded to a number of questions raised.

What are the main challenges to the Human Rights of older people to receiving treatment in hospital and residential care homes? Do the same problems arise in both settings?

The main challenges in hospital are the perceptions that:

Older people do not respond to treatment as well as younger people do.
It is acceptable to deny dignity and privacy to older people in a mixed ward.
Ill health is part of ageing and that frailty secondary to chronic disease is not treatable.
It is acceptable to use the toilet in a mixed ward next to a person of the opposite sex, separated by an insubstantial curtain.
It is acceptable to move an older person to another ward without advance warning because of bed pressures.

In both hospital and residential care homes:

Older people, who have difficulty feeding themselves, may not receive adequate nutrition as there are not sufficient staff numbers identified to feed them.
Older people may be left soiled in their beds or chairs.
Older people may be told, “Do it in your pants, I do not have time to change you and I will come back later.”
Older people may be publicly reprimanded for soiling themselves.
Older people’s visual and hearing problems may not be identified, treated or managed.
An assumption may therefore be made that they are either stupid or lacking in capacity.

In addition older people in care homes have their human rights infringed in the following ways:

They may be placed in care homes without adequate opportunities for assessment and rehabilitation to maximise their function. This raises issues under Article 8 (right to respect for private life).
Some older people go into long-term care without receiving a comprehensive assessment of their needs. This raises issues under Article 8 and, in extreme cases, 2 (right to life).
Their conditions may be left untreated until crises arise, as it is perceived that they are in a place of safety. This raises issues under Article 2.
There is a delay in the medical information about new residents being sent to the homes’ General Practitioners (GPs). This causes problems with continuity of care and a failure to understand the unique health needs of each resident. This raises issues under Articles 8 and 2.
Older people in care homes may be given sedatives, tranquillisers and restrained physically. This can arise as a result of inadequate levels of staff, skills and training and it raises issues under Articles 8 and 3 (prohibition of inhuman and degrading treatment).
Ambiguity in the case law means that the extent to which the Human Rights Act applies to the voluntary and private care home sector is currently unclear. (The Committee is concurrently exploring issues relating to the definition of ‘public authority’ in the Human Rights Act despite 60% of older residents receiving public funding for their care in these homes).
The population of care homes has become increasing frail and dependant over the last 20 years. There is very little difference between those receiving NHS Continuing Care and care home residents. There has been no shift of resources from the NHS to the community to care for this increasingly dependant group of the population. This raises issues under Article 8 and, in extreme cases, Article 2.
GPs and District Nurses regard their responsibilities in care homes as additional to their normal workload and an area for which they have not received any specialist training.
Only 40% of the GPs will have received any postgraduate training in the care of frail older people with multiple pathology. This results in older frail people in care homes receiving sub-standard treatment.
Nearly half of care homes are failing to meet national minimum standards for how they administer medication, prescribed for patients by their doctors, to treat their medical conditions. This raises issues under Articles 8 and, in extreme cases, 2.
Older people can be given the wrong medication, someone else’s medication, medication in the wrong doses or no medication at all. This raises issues under Articles 8 and, in extreme cases, 2.
Many older people residing in care homes would benefit from multi-disciplinary rehabilitation and medical treatment for their chronic diseases, but cannot access it. This raises issues under Article 8.
Reversible mental health conditions such as depression are not diagnosed and are not treated. This raises issues under Articles 8 and, in extreme cases, 2.

Are there discriminatory restrictions of the rights of older people to access health care without justification, for example in relation to criteria used for sharing or rationing finite health resources?

Older people admitted with trauma and fractures, which require surgery, may have their operation delayed, as younger patients with or without trauma may take precedence.
Older people who suffer delays for operations for fractured neck of femur, have been found to have a worse outcome in terms of morbidity and morality.
In some units older people may be refused surgery as their outcomes may be perceived as poor and this may affect the surgeons’ outcome figures.
This approach will deny older people access to successful interventions.
In some units they may have greater difficulty accessing investigations because of their age. Examples include access to 24-hour tapes for identification of cardiac arrhythmias.
Older people often have their medical complaints put down to old age with phrases like “social admission”, “acopia”, “inappropriate admission” or “bed blocker” used when they have perfectly treatable illnesses which would benefit from intervention.
Older people with delirium are not identified and thus are not perceived as suffering from a treatable medical condition.
Medical conditions in older people suffering from dementia are considered not to be worth treating
Most older people with advanced dementia do not receive appropriate palliative care
There is the perception that older people are no longer wage earners and thus less important to treat.
Women over 70 are not entitled to breast screening.
Many older people in the UK cannot get help with podiatry (foot care) from the NHS, leaving them in pain, housebound and at increased risk of falls, and in extreme cases unable to mobilise.
What barriers face older people, and their families, seeking to voice their concerns about possible abuse, neglect or discrimination in healthcare?
Staff are too busy to set aside a specific time to listen to concerns.
Older people tend to face barriers such as an assumption that they are too confused to be able to be an accurate observer.
Disabled older people are seen as less worthy of equitable healthcare than younger people with a single pathology.
An older person may feel less confident about speaking out as they fear there may be reprisals. Similarly their families will be concerned that if they voice their concerns, their relatives’ care may suffer.
Elder abuse does not have the same high profile as child abuse and as a consequence may be missed or mishandled

Could older people receiving treatment in hospital, or in residential care, be better informed about human rights principles? If so, how could better information and involvement be achieved?

Older people receiving treatment in hospital or in residential care could be better informed about Human Rights principles.
Older people, or their surrogates, on entering hospital and care homes should be informed about their rights and responsibilities
Nurses, doctors and care staff should be educated about the importance of older people’s Human Rights. This could be achieved by a public information campaign and/or a bill of Rights for older frail people entering hospital or a care home.
Staff taught about Human Rights are able to look at things differently and stop thinking just about protecting themselves but about care from the residents’ as well as the families’ perspective.
What examples are there of health care professionals or other workers, or advocates for older people using human rights principles to secure the dignity of older people undergoing treatment for physical or mental illness?
The British Geriatrics Society in partnership with Age Concern England, the Department of Geriatric Medicine, Cardiff University, Carers UK, the Continence Foundation, Help the Aged, Incontact, the Royal College of Nursing have developed a Dignity toolkit, Behind Closed Doors, based on the principles of Human Rights.
Age Concern (in partnership with the Chair of the BGS Policy Committee) are running the “Hungry to be Heard campaign” on malnutrition in older people.

What are the main practical, management and resource considerations facing those working in healthcare settings, including residential homes, when seeking to protect the human rights of older people in their care?

Meeting NHS targets is used as an excuse to sacrifice the older person’s dignity and Human Rights
Senior managers have been heard to defend mixed sex wards on the grounds of safety and health care delivery. The consequences of this approach are not appreciated.
Providing safe health care is used as an excuse to sacrifice the older person’s dignity and Human Rights.
The main considerations facing those working in health care settings are those of time, money and human resources.
The needs of younger people with a single pathology take priority.
The availability of beds in either setting.
The need to make beds available for emergencies and thus to transfer a patient from one setting to another in the middle of the night.
Freeing up an A&E trolley to prevent longer than 4-hour trolley waits.
The failure to recognise the increasing complexity, frailty and dependency of older people in the hospital and care home settings over the last five to ten years.
The failure to provide staff with appropriate skills and in sufficient numbers to meet these changes.
Ageist attitudes still persist as well as low status for those caring for older patients.

Enclosed with the BGS’ submisstion was an example from the United States residential care sector, which succinctly sets out the Rights of the individual entering a care home.