In January 2021, the Office of National Statistics published its latest overview data of the UK Population. Among the trends identified was a continued shift in the age structure of the UK population towards older adults. The population aged 65 and over is growing faster than any other age group. This has implications for those working in healthcare now and in the coming years.
The GMC has produced an ethical hub for doctors containing useful advice, information and scenarios to assist doctors in providing appropriate care to older adults.
In many ways, the principles underlying the provision of good medical care are the same no matter the age of the patient. However, it’s helpful for medical students and all doctors to recognise there are a number of principles which may be of enhanced importance when caring for an older adult.
Treating patients with respect
It is important to treat all patients with respect and courtesy. You should not make assumptions about what a patient might understand or want based on their age, appearance or medical conditions.
Good communication tailored to the patient’s needs
Older adults may be more likely to experience physical or communication barriers which may inhibit their ability to participate in decision making and/or to convey their wishes clearly. Unless the situation requires emergency action to protect life or prevent a serious consequence or deterioration, you should take time to try to overcome any barriers.
For example, you may wish to involve others (with the permission of the patient) such as carers or relatives to facilitate communication. You should consider the possibility of using physical aids, such as audio aids or printed information with a suitable print size.
Good communication means paying attention to the patient in front of you and being seen to do so. Consider the following:
- Eye contact: good eye contact can help establish rapport and ensure a patient feels they have been heard.
- Being clear: when asking questions or giving advice to patients try to use clear terms the patient can understand and check their understanding.
- Supplementary information: when conveying information, it’s important to consider if written or audio information might help, depending on a particular patient’s needs.
Although it is important to ensure you communicate information to patients in clear terms they can understand, this should be done with respect. All healthcare staff should be aware of the potential issues which can arise from using a communication style which has been referred to as Elderspeak.
This has been described as a phenomenon where younger or working age adults communicate with older adults in a manner involving slow speech, the use of simple vocabulary and repetition. This can be seen as a negative form of communication and evidence suggests cognitively unimpaired older adults find this style patronising and condescending.
The presumption of capacity
Always bear in mind any adult should be presumed to have mental capacity to make decisions, unless proven otherwise. Each patient must be treated as an individual and if capacity is an issue, then it should be carefully assessed based on each patient’s individual presentation and the decision needing to be made at the time.
You should not make assumptions about what a patient might understand or want based on their age, appearance or medical conditions.
Even a patient known to have a degree of cognitive impairment may still have capacity to make some decisions. Every patient has the right to express their views and be involved in decision making as much as is possible.
Taking a full history
Older adults may have a large number of co-morbidities and be on a variety of medications. Detailed history taking is essential to ensure their current presentation is considered in context and a holistic approach can be taken.
Advance care planning
It’s important that patients have conversations about their future care with the team responsible for their treatment. This is especially true for patients:
- with life-limiting illnesses
- with illness that might cause them to lose capacity in future
- where there is a significant change in a chronic condition.
Advance care planning involves giving patients the chance to plan their future care and support, including medical treatment, when they have the capacity to do so. You should respect the decision of a patient who doesn’t want to discuss this topic.
Key elements of such conversations are what the patient wants to happen, what they don’t want to happen and who may speak on their behalf if they lose capacity. The discussion could be the patient’s first step towards completing an advance decision or power of attorney.
It’s important to make a record of any discussion and seek the patient’s consent to share details with relevant people such as any carers. The plan should be reviewed and updated regularly and at key points if the patient still has capacity, such as when there is a significant change in the patient’s condition or circumstances or when the patient is believed to be approaching the end of life.