[Palliative care and care for the elderly: Worlds to be reconciled around an ethic of vulnerability]. / Soins palliatifs et soins au grand âge : des univers à réconcilier autour d'une éthique de la vulnérabilité.

The ageing of Western societies is leading to a marked increase in mortality. Death and old age are now intertwined. This situation should be of particular concern to palliative care. But in reality, palliative care remains too inaccessible to the oldest sections of the population. Why this paradox? After reviewing the clinical and organisational reasons that are often given, we invite you to take a more global look, one that is both sociological and ethical.

Making a difference: Students' experiences with a dementia care program.

As the number of elderly citizens in general and the number of persons with dementia in particular rises, the importance of educating geriatric health care professionals increases. Recruitment is, however, impaired by negative stereotypes and insecurity. Previous research has shown that contact with the field of dementia care is important for students' motivation for choosing this career path. This paper presents an extracurricular psychomotor intervention program in which students through eight visits to elderly persons with dementia carry out an intervention involving direct individual contact. Eight psychomotor therapy students participated in follow-up focus group interviews. The purpose was to explore the motivational dynamics that make these experiences meaningful to students. Qualitative analysis of the students' self-assessed outcomes revealed three themes: The relational encounter, Discovering the person, and Making a difference. In combination these themes show important nuances to existing literature on student career dreams by pointing to the benefits of attending to the moment to moment changes in the care situation.

Perspectives of Veterans Affairs mental health providers on working with older adults with dementia and their caregivers.

Continuing education directed at building providers' skills and knowledge in geriatrics represents a practical approach to addressing the geriatric mental health (MH) care workforce shortage. To inform the development of professional training curricula, we surveyed MH providers (N = 65) at a Veterans Affairs medical center on working with older persons with dementia (PwD) and informal caregivers. Providers rated service provision to PwD and caregivers as highly important but endorsed modest self-efficacy. Half of respondents were minimally confident in managing risk of harm to self or others in a PwD. Respondents believed PwD can benefit from MH treatments, yet identified several barriers to providing care, including inadequate time and staffing resources. Interest in geriatric training topics was high. Findings demonstrate that MH providers at this site value care provision to PwD and caregivers, and desire additional training to serve this population. System-level barriers to MH care for PwD should also be identified and addressed.

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.

Too Old for Freedom? Not Too Late to Try.

The physical, psychological and social aspects of care for older adults in nursing homes has been the subject of research internationally for more than 50 years. Numerous guidelines, models and principles of care have been published, yet in many facilities the lack of care which is "person-focused" remains concerning. Potentially, a return to a basic set of simple principles guiding care, ones which are intrinsically focused on the person, would be of use. Despite the plethora of models within the human care literature, looking outside of this frame might be useful not only for those in aged care at the end of life, but for older individuals more broadly. The argument for examining the "Five Freedoms" for animal welfare, which are recognized and applied internationally, is made, and suggestions for adapting this for human care, consistent within a One Health framework, are offered.

Developing a Tool for Evaluating Ageism in Nursing Care of Older People in Kashan/Iran.

Ageism implies negative views and attitudes towards older people. These unconscious behaviors could make the elderly feel as if they were no longer useful for the family and community. Ageism is common in healthcare services. The objective of this study was to develop a tool to assess ageism in nursing care in Kashan/Iran 2015. This psychometric study was carried out in four stages: literature review for item generation; content validity testing; exploratory factor analysis (EFA) for evaluation of construct validity; and reliability assessment. The data analyzed with SPSS version 16. The final questionnaire had 24 items. The total CVI and CVR were 0.88 and 0.57. Explanatory factor analysis identified 3 factors of respecting older adult in nursing care (14 items); age discrimination and negative views towards older adults (5 items); attention to older adult and their basic caring needs (5 items). The three factors could explain 49.54% of variance. The test-re-test correlation stood at 0.9. The internal consistency of the questionnaire was Cronbach's alpha =0.85. A valid and reliable instrument for the evaluation of ageism in nursing care was developed in this study.

Toward a global geroethics - gerontology and the theory of the good human life.

Gerontologists have proposed different concepts for ageing well such as 'successful ageing', 'active ageing', and 'healthy ageing'. These conceptions are primarily focused on maintaining health and preventing disease. But they also raise the questions: what is a good life in old age and how can it be achieved? While medical in origin, these concepts and strategies for ageing well also contain ethical advice for individuals and societies on how to act regarding ageing and old age. This connection between gerontology and ethics is overlooked by both schools of thought. We thus develop this research programme for a systematic geroethics in four steps. First, we analyze 'successful ageing' as put forward by Rowe and Kahn as a paradigmatic example of a gerontological conception of ageing well. Then, in a second step, we move from criticisms within gerontology to an ethical perspective; in particular, we want to clarify the problem of the claim of universal validity of conceptions of the good life. In a third constructive step, we explain how the 'capabilities approach' could be applied in this context as a normative foundation for the implicit normative assumptions of gerontological conceptions of ageing well, such as a particular choice of functionings, the ethical relevance of human agency, and the resulting claims of individuals towards society. Finally, using a concept developed by the German philosopher Ursula Wolf, we systematically develop the different aspects of the connection between ageing well and the theory of the good life in their full complexity and show their interconnectedness.

How Surrogates Decide: A Secondary Data Analysis of Decision-Making Principles Used by the Surrogates of Hospitalized Older Adults.

BACKGROUND: Many hospitalized adults do not have the capacity to make their own health care decisions and thus require a surrogate decision-maker. While the ethical standard suggests that decisions should focus on a patient's preferences, our study explores the principles that surrogates consider most important when making decisions for older hospitalized patients. OBJECTIVES: We sought to determine how frequently surrogate decision-makers prioritized patient preferences in decision-making and what factors may predict their doing so. DESIGN AND PARTICIPANTS: We performed a secondary data analysis of a study conducted at three local hospitals that surveyed surrogate decision-makers for hospitalized patients 65 years of age and older. MAIN MEASURES: Surrogates rated the importance of 16 decision-making principles and selected the one that was most important. We divided the surrogates into two groups: those who prioritized patient preferences and those who prioritized patient well-being. We analyzed the two groups for differences in knowledge of patient preferences, presence of advance directives, and psychological outcomes. KEY RESULTS: A total of 362 surrogates rated an average of six principles as being extremely important in decision-making; 77.8% of surrogates selected a patient well-being principle as the most important, whereas only 21.1% selected a patient preferences principle. Advance directives were more common to the patient preferences group than the patient well-being group (61.3% vs. 44.9%; 95% CI: 1.01-3.18; p = 0.04), whereas having conversations with the patient about their health care preferences was not a significant predictor of surrogate group identity (81.3% vs. 67.4%; 95% CI: 0.39-1.14; p = 0.14). We found no differences between the two groups regarding surrogate anxiety, depression, or decisional conflict. CONCLUSIONS: While surrogates considered many factors, they focused more often on patient well-being than on patient preferences, in contravention of our current ethical framework. Surrogates more commonly prioritized patient preferences if they had advance directives available to them.

Technologies in older people's care.

BACKGROUND: The tension between care-based and technology-based rationalities motivates studies concerning how technology can be used in the care sector to support the relational foundation of care. OBJECTIVES: This study interprets values related to care and technologies connected to the practice of good care. RESEARCH DESIGN: This research study was part of a development project aimed at developing innovative work practices through information and communication technology. Participants and research context: All staff (n = 18) working at two wards in a care facility for older people were asked to participate in interviews, and 12 accepted. We analysed the data using latent content analysis in combination with normative analysis. Ethical considerations: The caregivers were informed that participation was voluntary and that they could drop out at any time without providing any explanation. FINDINGS: Four values were identified: 'presence', 'appreciation', 'competence' and 'trust'. Caregivers wanted to focus on care receivers as unique persons, a view that they thought was compromised by time-consuming and beeping electronic devices. Appraising from next-of-kin and been seen as someone who can contribute together with knowledge to handle different situations were other desires. The caregivers also desired positive feedback from next-of-kin, as they wanted to be seen as professionals who have the knowledge and skills to handle difficult situations. In addition, the caregivers wanted their employer to trust them, and they wanted to work in a calm environment. DISCUSSION: Caregivers' desire for disturbance-free interactions, being valued for their skills and working in a trustful working environment were interpreted as their base for providing good care. The caregivers' arguments are based on caring rationality, and sometimes they felt the technological rationality interfered with their main mission, providing quality care. CONCLUSION: Introducing new technology in caring should support the caring relationship. Although society's overall technology-based approach may have gained popularity as a problem solver, technology-based rationality may compromise a care-based rationality. A shift in attitudes towards care as a concept on all societal levels is needed.

[Organisational challenges of community information offices for the elderly in Switzerland : A qualitative study with ethical reflections]. / Strukturelle Herausforderungen kommunaler Altersstellen in der Schweiz : Eine qualitative Studie mit ethischer Reflexion.

BACKGROUND: Current Swiss politics concerning age and ageing are orientated towards the principle "out-patient before in-patient". As part of new regulations, in 2011 all communities were required to set up information offices to answer questions about out-patient and in-patient care. OBJECTIVES: The aim of this qualitative study was to analyse in which form and under which conditions such information offices are run. METHODS: A qualitative study was conducted which consisted of semistructured interviews with managers of information offices. They were analysed using qualitative content analysis. RESULTS: The analysis shows that on the one hand the information offices have the potential to serve an important role in the communities and that they have a highly complex, demanding and responsible function. On the other hand the results illustrate that in organisational respects the situation is highly heterogeneous and unregulated. CONCLUSION: For the running of the information offices, there is need for action such as the definition of general framework, quality standards, qualifications and values profiles, objectives, mission, responsibility and legitimation, instruments for networking and cooperations.

Ethical implications of home telecare for older people: a framework derived from a multisited participative study.

CONTEXT: Telecare and telehealth developments have recently attracted much attention in research and service development contexts, where their evaluation has predominantly concerned effectiveness and efficiency. Their social and ethical implications, in contrast, have received little scrutiny. OBJECTIVE: To develop an ethical framework for telecare systems based on analysis of observations of telecare-in-use and citizens' panel deliberations. DESIGN: Ethnographic study (observation, work shadowing), interviews, older citizens' panels and a participative conference. SETTING: Participants' homes, workplaces and familiar community venues in England, Spain, the Netherlands and Norway 2008-2011. RESULTS: Older respondents expressed concerns that telecare might be used to replace face-to-face/hands-on care to cut costs. Citizens' panels strongly advocated ethical and social questions being considered in tandem with technical and policy developments. Older people are too often excluded from telecare system design, and installation is often wrongly seen as a one-off event. Some systems enhance self-care by increasing self-awareness, while others shift agency away from the older person, introducing new forms of dependency. CONCLUSIONS: Telecare has care limitations; it is not a solution, but a shift in networks of relations and responsibilities. Telecare cannot be meaningfully evaluated as an entity, but rather in the situated relations people and technologies create together. Characteristics of ethical telecare include on-going user/carer engagement in decision making about systems: in-home system evolution with feedback opportunities built into implementation. System design should be horizontal, 'two-way'/interactive rather than vertical or 'one-way'. An ethical framework for telecare has been developed from these conclusions (Table 1).

Inequity in oral health care for elderly Canadians: part 2. Causes and ethical considerations.

The Canadian Health Measures Survey, conducted between March 2007 and February 2009, revealed unmet dental needs among older adults in Canada. This article, the second of a 3-part series, explains that the inequity in oral care faced by elderly Canadians is due largely to the current fee-for-service dental service system. However, the inequity has arisen because of financial, behavioural and physical barriers, and both the community at large and the dental profession have a social responsibility to reduce this unfairness and provide equitable access to oral care for older people.

Inadequate treatment for elderly patients: professional norms and tight budgets could cause "ageism" in hospitals.

We have studied ethical considerations of care among health professionals when treating and setting priorities for elderly patients in Norway. The views of medical doctors and nurses were analysed using qualitative methods. We conducted 21 in depth interviews and 3 focus group interviews in hospitals and general practices. Both doctors and nurses said they treated elderly patients different from younger patients, and often they were given lower priorities. Too little or too much treatment, in the sense of too many interventions and too much drugs, combined with too little care and comfort, was admitted as a relatively frequent yet unwanted consequence of the way clinical priorities were set for elderly patients. This was explained in terms of elderly patients not tolerating the same treatment as younger patients, and questions were raised about the quality of life of many elderly patients after treatment. These explanations were frequently referred to as medically sound decision making. Other explanations had little to do with medically sound decisions. These often included deep frustration with executive guidelines and budget constraints.

Justice between age groups: an objection to the prudential lifespan approach.

Societal aging raises challenging ethical questions regarding the just distribution of health care between young and old. This article considers a proposal for age-based rationing of health care, which is based on the prudential life span account of justice between age groups. While important objections have been raised against the prudential life span account, it continues to dominate scholarly debates. This article introduces a new objection, one that develops out of the well-established disability critique of social contract theories. I show the implications of this critique for the prudential life span account and for the special case of age-group justice. The result is that age-based rationing based on the prudential life span approach is not supported, and that the prudential life span approach itself is not the best way to think about allocating health care between age groups. I propose an alternative approach that avoids the disability objection, and consider its implications for specific proposals for age-based rationing of health care.

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.

Respect in the care of older patients in acute hospitals.

The aim of this study was to describe the experiences of older patients and their next of kin with regards to respect in the care given in an acute hospital. The data were collected using tape-recorded interviews (10 patients and 10 next of kin) and analysed via inductive content analysis. Based on the analysis, the concept of respect can be defined by the actions taken by nurses (polite behaviour, the patience to listen, reassurance, response to information needs, assistance in basic needs, provision of pain relief, response to wishes and time management) and next of kin (support, assistance and advocacy) and by factors related to the environment (appreciation of older people in society, management of health-care organizations, the nursing culture, the flow of information and patient placement). The information will be used to develop an instrument for assessing how well respect is maintained in the care of older patients.

Dealing with troubled conscience in municipal care of older people.

Troubled conscience may jeopardize the health of healthcare personnel and, hence, the quality of care provided. Learning more about how personnel deal with their troubled conscience therefore seems important. The aim of this study was to describe personnel's experiences of how they deal with troubled conscience generated in their daily work in municipal care of older people. Interviews were conducted with 20 care providers and analysed with a thematic content analysis. The findings show that in order to deal with troubled conscience, personnel dialogued with themselves and with others. They took measures in a direction they perceived to be correct, and they expressed a need for distancing and re-energizing. It is of importance to share situations that generate troubled conscience in order to find ways to deal with them. Reconsidering one's ways of dealing with troubled conscience may give care providers an opportunity to reach consensus within themselves.

The eldercare factory.

Rapid advances in service robotics together with dramatic shifts in population demographics have led to the notion that technology may be the answer to our eldercare problems. Robots are being developed for feeding, washing, lifting, carrying and mobilising the elderly as well as monitoring their health. They are also being proposed as a substitute for companionship. While these technologies could accrue major benefits for society and empower the elderly, we must balance their use with the ethical costs. These include a potential reduction in human contact, increased feeling of objectification and loss of control, loss of privacy and personal freedom as well as deception and infantilisation. With appropriate guidelines in place before the introduction of robots en masse into the care system, robots could improve the lives of the elderly, reducing their dependence and creating more opportunities for social interaction. Without forethought, the elderly may find themselves in a barren world of machines, a world of automated care: a factory for the elderly.