Potential prescribing omissions according to START criteria at the time of hospital discharge

The purpose of this study is to describe the frequency of potential drug prescribing omissions (PPOs) for elderly patients at the time of hospital discharge and to compare the frequency PPOs among different medical specialities. This cross-sectional study examined data from elderly patients when they were admitted for >24 h to a northeastern Brazil teaching hospital during June-December 2016. Were included in the study 227 patients, of whom 36.9% had at least one PPO. The highest number of PPOs was identified among those with at least 5 prescribed drugs. In total, 153 PPOs were identified at hospital discharge. In most cases (78.4%), patients were not evaluated by the specialist physician.The most commonly identified PPOs on discharge were: the omission of statin therapy in cases of diabetes mellitus plus one or more cardiovascular-associated factor; calcium and vitamin D supplements in patients with known osteoporosis; and angiotensin converting enzyme inhibitors in cases of chronic heart failure. The results of this study suggest that the frequency of prescribing omissions PPOs during patient discharge was high. This can be avoided by the careful evaluation by prescribers with experience in certain specialties where several prescribed omissions would be common.

COVID-19 outbreak: organisation of a geriatric assessment and coordination unit. A French example.

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient's level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory.

Caring for Frail Older Adults During COVID-19: Integrating Public Health Ethics into Clinical Practice.

During the coronavirus disease 2019 (COVID-19) pandemic, principles from both clinical and public health ethics cue clinicians and healthcare administrators to plan alternatives for frail older adults who prefer to avoid critical care, and for when critical care is not available due to crisis triaging. This article will explore the COVID-19 Ethical Decision Making Framework, published in British Columbia (BC), Canada, to familiarize clinicians and policy makers with how ethical principles can guide systems change, in the service of frail older adults. In BC, the healthcare system has launched resources to support clinicians in proactive advance care planning discussions, and is providing enhanced supportive and palliative care options to residents of long-term care facilities. If the pandemic truly overwhelms the healthcare system, frailty, but not age alone, provides a fair and evidence-based means of triaging patients for critical care and could be included into ventilator allocation frameworks. J Am Geriatr Soc 68:1666-1670, 2020.

Ethical issues in nursing home palliative care: a cross-national survey.

OBJECTIVES: With an increased dependency on nursing homes to provide care to the ageing population, it is likely that ethical issues will also increase. This study aimed to identify the type of ethical issues and level of associated distress experienced by nurses providing palliative care in nursing homes in the UK and Canada, and pilot the Ethical issues in Palliative Care for Nursing Homes (EPiCNH) instrument in Canada. METHODS: A cross-sectional survey design was used. One hundred and twenty-three nurses located in 21 nursing homes across the UK and Canada completed the EPiCNH instrument. RESULTS: Frequent ethical issues include upholding resident autonomy, managing family distress, lack of staff communication and lack of time in both countries. Higher levels of distress resulted from poor communication, insufficient training, lack of time and family disagreements. Nurses in Canada experienced a greater frequency of ethical issues (p=0.022); however, there was no statistical difference in reported distress levels (p=0.53). The survey was positively rated for ease of completion, relevance and comprehensiveness. CONCLUSIONS: Nurses' reported comparable experiences of providing palliative care in UK and Canadian nursing homes. These findings have implications on the practice of care in nursing homes, including how care is organised as well as capacity of staff to care for residents at the end of life. Training staff to take account of patient and family values during decision-making may address many ethical issues, in line with global policy recommendations. The EPiCNH instrument has demonstrated international relevance and applicability.

Relational approach to ethics and quality improvement in institutional care for people with dementia.

BACKGROUND: Autonomy has become a key organizing principle in the official and expert discourses of the social services focused on strengthening of clients' independence and self-sufficiency. While "caring" has been seen as a threat to the autonomy of an individual, the care dependency and need for palliative care for people with dementia living in residential institutions are growing. METHODS: Participatory action research was realized in 9 homes providing services for people with dementia with the aim to improve the quality of care. Research teams from the homes were involved in assisted self-assessment which included observation, documentation analysis, workshops, interviews and interventions targeting the issues arising from practice. Ethnographic research was performed by the consultant/researcher to reflect on the experience. RESULTS: Over the last 15 years, the needs of clients in the residential care institutions in the Czech Republic have changed significantly and the pressure on people involved in direct care is growing. I suggest that relational approach to care, enhancing personal commitment of care workers and their appreciation of sociomateriality of caring relations, is well suited for enacting autonomy and dignity of people living and dying with dementia. The relational approach to care improvement is embedded in everyday practices and thus brings a wider scope of possibilities for providing good care than the controlling mode of improvement, measuring evidence against the national standards. CONCLUSIONS: If we are, as a collective, to build up appropriate structures and resources in dementia care, more attention must be paid to the needs of residents and care workers alike, as well as to realities of the daily practices.

Treatment ethics, quality of life and health economics in the management of hematopoietic malignancies in older patients.

The prevalence of diseases such as AML or myelodysplastic syndromes increases with the aging of the population. Only intensive chemotherapy or hematopoietic cell transplantation have curative potential. However, comorbid conditions may interfere with effective therapy. Although transplantation following low-intensity conditioning is being carried out in patients even in their 70s, these are highly selected patients, and the data cannot be extrapolated to the population at large. Further, such a therapy in older individuals may be associated with considerable morbidity and the need for prolonged hospitalization and rehabilitation, stressing the system and draining family resources. As the focus of many older individuals is on quality of life, it is important to emphasize that, for various advanced malignancies, emerging data indicate that quality of life may be better and survival may be longer with palliative care. A re-assessment of treatment decisions in older patients is in order. We tend to 'oversell', and particularly older patients do not have a full understanding of the impact of the proposed therapy on their lives. Our conversations with these patients must include a discussion of supportive/palliative care and must address end-of-life issues. Talking about death may mean talking about life.

Valoración Geriátrica Integral / Comprehensive Geriatric Assessment

El paciente geriátrico es un paciente de especiales características en el que confluyen características propias del envejecimiento fisiológico y las formas especiales de presentación de las patologías, lo que hace necesaria una valoración especial, la Valoración Geriátrica Integral (VGI), la cual nos permite de una manera global valorar las características de éste tipo de pacientes que se escaparían de una valoración clínica usual, que comprende sólo anamnesis y exploración física. La VGI es "un proceso diagnóstico evolutivo multidimensional (porque analiza las diferentes esferas que integran al individuo) e interdisciplinario (interdisciplinaria porque en esta participan diferentes profesionales médicos, enfermeras y asistentes sociales), diseñado para identificar y cuantificar los problemas físicos, funcionales, psíquicos y sociales que puedan presentar los adultos mayores, especialmente los más frágiles, con el propósito de desarrollar un plan individualizado de cuidados integrales, que permita una acción preventiva, terapéutica, rehabilitadora y de seguimiento, con la óptima utilización de recursos, a fin de lograr el mayor grado de autonomía y mejorar la calidad de vida del adulto mayor." Constituye la herramienta fundamental del trabajo del clínico que atiende pacientes dentro del campo geriátrico. Un reciente metanálisis concluyó que los ancianos hospitalizados que se les realizó VGI incrementaron la posibilidad de permanecer vivos en su propia casa, es decir, menos probabilidades de institucionalizarse, de presentar deterioro funcional o de morir, además de experimentar mejoría de la cognición en un máximo de 12 meses comparado con pacientes de las mismas características...(AU)

The geriatric patient is a patient of special features, in which the physiological aging and the special forms of presentation of the pathologies come together which makes a special evaluation necessary such as the Integral Geriatrical valuation (VGI), which allows us with a global approach to value the characteristics of this type of patients, since could be escape of a usual clinical evaluation, this include only anamnesis and physical examination. The VGI it is "a evolutive multidimensional process of diagnosis (because it analyzes different spheres that integrates the individual) and interdisciplinary (interdisciplinary because of the participation of different areas as doctors, nurses and social assistants), designed to identify and quantify physical, functional, psychic and social problems who can present the elderly population, specially the most weak ones, in order to develop an individualized plan of integral cares, that allows preventive, therapeutic , rehabilitative and the follow up antions , with the optimal uses of the resources, in order to obtain a greater degree of autonomy to improve the quality of life of the elderly patients" It is the fundamental tool of work of the clinicians that takes care of elderly patients. A recent meta analysis study concluded that the elderly hospitalized patients that were evaluated with the VGI , increased the possibility of remaining alive at community field at home, it means. less possibilities to received hospitalization and reducing the possibilities to present functional deterioration or of dying, besides to experience improvement of the cognition in a maximum of 12 months compared with patients of the same characteristics.

Patient neglect in healthcare institutions: a systematic review and conceptual model.

BACKGROUND: Patient neglect is an issue of increasing public concern in Europe and North America, yet remains poorly understood. This is the first systematic review on the nature, frequency and causes of patient neglect as distinct from patient safety topics such as medical error. METHOD: The Pubmed, Science Direct, and Medline databases were searched in order to identify research studies investigating patient neglect. Ten articles and four government reports met the inclusion criteria of reporting primary data on the occurrence or causes of patient neglect. Qualitative and quantitative data extraction investigated (1) the definition of patient neglect, (2) the forms of behaviour associated with neglect, (3) the reported frequency of neglect, and (4) the causes of neglect. RESULTS: Patient neglect is found to have two aspects. First, procedure neglect, which refers to failures of healthcare staff to achieve objective standards of care. Second, caring neglect, which refers to behaviours that lead patients and observers to believe that staff have uncaring attitudes. The perceived frequency of neglectful behaviour varies by observer. Patients and their family members are more likely to report neglect than healthcare staff, and nurses are more likely to report on the neglectful behaviours of other nurses than on their own behaviour. The causes of patient neglect frequently relate to organisational factors (e.g. high workloads that constrain the behaviours of healthcare staff, burnout), and the relationship between carers and patients. CONCLUSION: A social psychology-based conceptual model is developed to explain the occurrence and nature of patient neglect. This model will facilitate investigations of i) differences between patients and healthcare staff in how they perceive neglect, ii) the association with patient neglect and health outcomes, iii) the relative importance of system and organisational factors in causing neglect, and iv) the design of interventions and health policy to reduce patient neglect.

Risk, governance and the experience of care.

Drawing on perspectives from the governmentality literature and the sociology of risk, this article explores the strategies, tools and mechanisms for managing risk in acute hospital trusts in the United Kingdom. The article uses qualitative material from an ethnographic study of four acute hospital trusts undertaken between 2008 and 2010 focusing on the provision of dignified care for older people. Extracts from ethnographic material show how the organisational mechanisms that seek to manage risk shape the ways in which staff interact with and care for patients. The article bridges the gap between the sociological analysis of policy priorities, management strategy and the organisational cultures of the NHS, and the everyday interactions of care provision. In bringing together this ethnographic material with sociological debates on the regulation of healthcare, the article highlights the specific ways in which forms of governance shape how staff care for their patients challenging the possibility of providing dignified care for older people.

Valoración biopsicosocial del adulto mayor desde un enfoque bioético en una población cubana / Biopsychosocial assessment of the older adult from a bioethical approach in a Cuban population section

Objetivo: explorar la situación biopsicosocial del adulto mayor en una población del municipio Arroyo Naranjo. Métodos: estudio de tipo observacional, descriptivo longitudinal y prospectivo. El instrumento utilizado fue una encuesta original elaborada por los autores y validada por un comité de expertos, representados por psicólogos, y geriatras y que se les aplicó a 400 personas mayores de 60 años entre enero y diciembre de 2007. Se confeccionó una base de datos con la información de las entrevistas y se obtuvieron los porcentajes de las variables seleccionadas. Resultados: el 88,2 porciento (353 abuelos) de los encuestados padecían al menos de una enfermedad crónica. Se sintieron maltratados en el consultorio del médico y enfermera de la familia, los policlínicos, las clínicas estomatológicas y hospitales, en un 14,7, 9,2, 11,5 y 9,5 porciento respectivamente. El 19,8 porciento de los adultos mayores considera que sus familiares no le brindan el apoyo que necesitan. El 44,2 porciento representado por 177 ancianos de los tres grupos, plantea que sí existe discriminación con el adulto mayor. Conclusiones: la asistencia médica es buena, pero en un pequeño porcentaje no fue la mejor, se violaron los principios de beneficencia, no maleficencia, justicia y autonomía. Los círculos de abuelos y la casa de abuelos, ayudan al adulto mayor a mantenerse integrado a la sociedad

Objective: to assess the biological, psychological and social situation of the older people in a population living in Arroyo Naranjo municipality. Methods: prospective, observational and descriptive study was conducted in which an original survey prepared by the authors of the paper and validated by an expert committee of psychologists and geriatricians was used. Four hundred people over 60 years were surveyed from January to December, 2007. They were divided in three groups based on their participation in the grandparent's clubs, the homes for grandparents and those not involved in neither of the former. Data from the interviews were included in a database and the percentages of the selected variables were estimated. Results: of the participants, 88.2 percent (353 grandparents) suffered at least one chronic disease. They felt ill-treated in the family physician's office, in the polyclinics, at the dental clinics and at hospitals in 14.7 percent, 9.2 percent, 11.5 percent and 9.5 percent of the sample, respectively. In this study, 19.8 percent of the older people believed that their families did not support them as they should. One hundred seventy seven of the participants, who accounted for 44.2 percent of the total number, stated that the elderly are discriminated. Conclusions: medical assistance is good; however it was not the best in a small percentage of cases, since the principles of benefaction, non-malefaction, justice and autonomy were not respected. The grandparents' clubs and the homes for grandparents do help the older people to remain integrated to the society

[Setting up of a community/hospital network providing care for patients and their families]. / Mise en place d'une structure ville/hôpital de prise en charge des patients et de leurs familles.

With the ageing of the population, dementia has become a public healthcare priority. A network designed to help the families of patients suffering from dementia on a medical as well as a social and psychological level has been set up. This structure has been developed in close coordination with community practitioners and physicians and in line with the latest recommendations in particular with regard to ethics. Its first three years of existence confirm the importance of this type of approach which complements the care provided by hospitals.

[Quality of life and ethics as basic questions in geriatric oncology]. / Lebensqualität und Ethik als wichtige Grundsatzfragen der geriatrischen Onkologie.

Optimal care for elderly cancer patients requires empathy and alertness about impaired autonomy and an exceptional quality of care. Specific to geriatric oncology is the particular need of attention and care for the patients. Most important from a conceptual point of view is to identify that this will result in additional demands. To care for these patients will require more time as any intervention must be adapted to age specific capabilities. The difficult task of shared decision-making should be preferably based on the quality of life assessment of the individual patient and their needs. The process of assessing quality of life is in itself already an act of enhancing autonomy, because it respects the individual's subjectivity. Many ethical questions arise between the contradictory contexts of paternalism and autonomy. There are conditions to be met and limits of autonomy to be considered, which differ for the elderly patients because of their vulnerability and particular dependencies. As the elderly patient is closer to death and dying, questions of care in these situations are frequently more pressing. It is important to distinguish actively intended euthanasia from the goals and concerns of modern palliative care in order to enable dying with dignity.

A cross cultural review of the ethical issues in dementia care in Kerala, India and The Netherlands.

BACKGROUND: The paper explores the diverse ethical issues in the care of persons with dementia, in the Netherlands and Kerala, India. These cross-cultural data are used to suggest newer ways for addressing the ethical issues in a mutually enhancing manner. METHODS: A thorough review of the literature focusing on ethical aspects of the care for persons with dementia. RESULTS: The medical paradigm is dominant in the Netherlands and awareness of dementia as an organic brain disease is low in Kerala. Institutionalized care is more common in the Netherlands and home-based care is the norm in Kerala. Institutional care is costly, whereas home-based care is stressful for caregivers. The advanced directive plays an influential role in the Netherlands, but this mechanism is yet to evolve in Kerala. The legal and social setting of the Netherlands has a strong influence on physician decision-making concerning end of life issues. In Kerala, discussion of these matters is nearly unknown. CONCLUSION: Limited awareness of dementia in Kerala should be addressed in public forums, which can then be used to garner governmental support. The predominantly institutional model of care-giving in the Netherlands and home-based care-giving in Kerala, each have their strengths; policy makers in both societies can usefully apply the values and merits inherent in both models. A culturally appropriate implementation of the advanced directive will have beneficial medical, social, and economic impacts in Kerala. The remarkable disparity between the Netherlands and Kerala in dealing with end-of-life issues will allow more philosophically and socially informed ways of addressing the ethical questions that arise in those situations.

Operacionalização das políticas de atenção ao idoso: um olhar avaliativo sobre algumas experiências no município do Rio de Janeiro / Operationalization of public policies for the elderly: an evaluation about some experiences in the city of Rio de Janeiro

Diante do crescente envelhecimento populacional, a operacionalização das políticas de atenção à pessoa idosa torna-se um desafio. Há que se propor estratégias que possam melhor nortear as ações e serviços. Neste sentido, este trabalho propôs-se a avaliar algumas iniciativas em andamento no município do Rio de Janeiro, considerando o Projeto Longevidade e o Programa de Atenção Básica à Saúde do Idoso (PSI), desenvolvidos pela Secretaria Extraordinária de Qualidade de Vida (SEQV) e pela Gerência de Programas de Saúde do Idoso (GPI), respectivamente. Como parâmetros estruturantes da pesquisa foram considerados os pressupostos da análise de intervenção e, de modo a oferecer respaldo teórico para a avaliação proposta, as concepções de velhice e promoção de saúde defendidas pelos projetos foram ressaltadas sob a ótica da Gerontologia. O material empírico consistiu na análise do conteúdo de entrevistas semiestruturadas com os representantes dos projetos, objetivando configurar o direcionamento dado às ações desenvolvidas. O relato dos gestores pareceu denotar certa fragilidade estrutural, dificultadora da efetivação da assistência. Constatou-se, a partir da contextualização dos projetos, que mediante maior articulação interinstitucional e construção de espaços de discussão onde a velhice seja prioridade, o estabelecimento de estratégias em consonância com os princípios legais instituídos poderá tornar-se uma realidade.

O processo de constituição e funcionamento de um Conselho Municipal dos Direitos do Idoso: o caso do município de Maringá-PR / The process of establishment and operation of a Municipal Board of Rights of the Elderly: the case of the municipality of Maringá-PR, Brazil

O envelhecimento populacional é um processo que produz impacto nas relações sociais e nas políticas públicas. Os Conselhos de Direitos do Idoso surgem no cenário nacional como uma inovação institucional, para exercer controle democrático entre o Estado e a sociedade no tocante à pessoa idosa. Este trabalho propôs-se a olhar para o processo de constituição e funcionamento do Conselho Municipal dos Direitos do Idoso (CMDI) de Maringá, localizado no Estado do Paraná. Para tanto, realizamos entrevistas com conselheiros, que foram complementadas pela análise de documentos do CDMI de Maringá. O CDMI estudado não surgiu de um amplo movimento social em torno das questões do idoso. Ele decorreu de uma ação de técnicos da Secretaria de Assistência Social, que buscaram ativamente a interface com entidades do movimento social. Por sua vez, o Conselho parece se constituir como um campo de práticas, no qual tanto representantes do movimento social como representantes do governo vão constituindo significados para o que é ser conselheiro. Assim, convivem distintas acepções. De um lado, técnicos das diversas secretarias oscilam entre a idéia de que devem defender as posições de suas secretarias e da gestão municipal, e a de que, ao se tornarem conselheiros, devem se pautar pela defesa dos direitos do idoso. De outro, participantes que vão, em sua trajetória como conselheiros, descobrindo os potenciais da participação nas discussões de projetos e propostas relativos ao idoso...

Envelhecimento, ciclo de vida e mudanças socioeconômicas: novos desafios para os sistemas de seguridade social / Ageing, life cycle and socioeconomic changes: new challenges for social security systems

O processo de envelhecimento populacional, ainda que amplamente reconhecido como uma das principais conquistas do século XX engendra o desafio de assegurar que o processo de desenvolvimento ocorra com base em princípios capazes de garantir a dignidade humana e a eqüidade entre os grupos etários na partilha dos recursos, direitos e responsabilidades sociais. Além dos desafios impostos aos já tradicionais programas constantes dos atuais sistemas de seguridade social, o envelhecimento populacional acrescenta uma nova questão ou risco social: os cuidados de longa duração, demandados pelos idosos com perda de capacidade instrumental e/ou funcional para lidar com as atividades do cotidiano. Por capacidade instrumental pode-se entender a capacidade para a realização de atividades relacionadas a, por exemplo: preparar refeições, fazer compras no mercado, ir ao banco, cuidar da casa etc. Capacidade funcional, por sua vez, refere-se às seguintes atividades: alimentar-se, banhar-se, caminhar distâncias curtas, vestir-se etc. A preocupação com os cuidados de longa duração dos idosos nos países desenvolvidos, onde o processo de envelhecimento populacional já se encontra mais avançado, surgiu como uma necessidade de se separar os custos crescentes com o tratamento dos idosos dos demais gastos com saúde. Os custos, tangíveis ou não, envolvidos na atividadede cuidar/assistir aos idosos tendem a aumentar em função da entrada maciça das mulheres no mercado de trabalho e das mudanças nos contratos de gênero, sugerindo crescentes dificuldades para que as famílias arquem com a responsabilidade pelo cuidado de seus idosos. Em países em desenvolvimento, como o Brasil, essa questão é agravada por se somar a uma ampla lista a ser respondida pelos sistemas de seguridade social, tais como a pobreza, a exclusão de crescentes contingentes da população e o nível de desigualdade vigente...

Operacionaliação das políticas de atenção ao idoso: um olhar avaliativo sobre algumas experiências no município do Rio de Janeiro / Operationalization of public policies for the elderly: an evaluation about some experiences in the city of Rio de Janeiro

Diante do crescente envelhecimento populacional, a operacionalização das políticas de atenção à pessoa idosa torna-se um desafio. Há que se propor estratégias que possam melhor nortear as ações e serviços. Neste sentido, este trabalho propôs-se a avaliar algumas iniciativas em andamento no município do Rio de Janeiro, considerando o Projeto Longevidade e o Programa de Atenção Básica à Saúde do Idoso (PSI), desenvolvidos pela Secretaria Extraordinária de Qualidade de Vida (SEQV) e pela Gerência de Programas de Saúde do Idoso (GPI), respectivamente. Como parâmetros estruturantes da pesquisa foram considerados os pressupostos da análise de intervenção e, de modo a oferecer respaldo teórico para a avaliação proposta, as concepções de velhice e promoção de saúde defendidas pelos projetos foram ressaltadas sob a ótica da Gerontologia. O material empírico consistiu na análise do conteúdo de entrevistas semiestruturadas com os representantes dos projetos, objetivando configurar o direcionamento dado às ações desenvolvidas. O relato dos gestores pareceu denotar certa fragilidade estrutural, dificultadora da efetivação da assistência. Constatou-se, a partir da contextualização dos projetos, que mediante maior articulação interinstitucional e construção de espaços de discussão onde a velhice seja prioridade, o estabelecimento de estratégias em consonância com os princípios legais instituídos poderá tornar-se uma realidade.

Ética na atenção ao paciente idoso / Ethics in attention to aged patient

O Código de Ética Médica é instrumento de balizamento dos valores éticos da profissão médica e, como tal, deve ser seguido com zelo por todos os médicos. Os pacientes têm o direito à informação individualizada e verdadeira, tanto quanto ao diagnóstico quanto à terapêutica, e ao consentimento na decisão terapêutica e nos atos a serem praticados. O paciente precisa saber que é vedado ao médico revelar fato de que tenha conhecimento em virtude do exercício de sua profissão, salvo por justa causa, dever legal ou autorização expressa do mesmo, mesmo que tenha falecido. A observância destes itens reforça uma boa relação médico-paciente...