This collection of discussions among healthcare professionals delves into various aspects of geriatric care, covering topics such as informed consent in emergencies, the social and psychological aspects of elderly care, the role of nurse practitioners, home-based training, government schemes, and community services. 

These conversations highlight the challenges, gaps, and potential solutions to providing comprehensive care to the elderly population. Training, awareness, and legal support are essential to ensure that geriatric patients receive the care they deserve. While acknowledging the existing initiatives, the need for increased implementation and education to bridge gaps in geriatric care becomes evident.

Case study

An 82-year-old woman, Mrs. A, had been experiencing symptoms suggestive of a lower respiratory tract infection for one week. Upon her arrival at the emergency department of a hospital, she was in respiratory distress and required ventilator support. A caregiver accompanied her, and she was brought to the hospital via ambulance. Her son, who resides in the United States, was her primary contact, and there was limited available information regarding her medical history during the initial assessment. In response to her worsening respiratory condition, the emergency department resident promptly intubated Mrs. A to address the impending respiratory distress. Basic diagnostic tests were initiated, and once her condition stabilized, she was transferred to the geriatric care unit. Importantly, the caregiver’s consent was obtained before the initial medical interventions were performed, not post-admission. Subsequently, Mrs. A’s son informed the on-call resident that his mother had a history of multiple myeloma and had completed chemotherapy. However, she had been bedridden due to significant back pain for over two years. The son expressed his dissatisfaction and unhappiness with the medical team’s decision to place his mother on a ventilator. Healthcare professionals, including treating physicians, geriatricians, and emergency department staff, commonly encounter these types of scenarios in their day-to-day practice.

The patient is put on a ventilator, and while she does respond to oral commands, her blood pressure is being maintained.She is receiving IV antibiotics and supportive care, which has led to an improvement in her sodium levels.

However, it has proven challenging to wean her off the ventilator, as she has been ventilator-dependent for over seven days. On the seventh day, the medical team discussed the possibility of a tracheostomy with the family over the phone. Several critical issues are at play in this case. Medically, there is difficulty in weaning the patient off the ventilator, given her background of multiple myeloma, a history of recurrent pneumonia, being bedridden for more than two years, and her frail condition with sarcopenia. Socially, the patient’s son is not present, and she is cared for by a caregiver, with financial support provided by her son, who lives abroad. Ethically, there are concerns about the validity of consent given over the phone, especially since everything has been conveyed to the son through this method. Additionally, the role of the caregiver in the consent process needs to be addressed.

Dr. Prabha

What is the significance of informed consent and ethical issues in the context of obtaining consent? Also, is consent obtained over the phone legally valid? 

When discussing consent for emergency patient care, it’s important to understand that telephonic consent is legally valid for initiating ventilator support in urgent situations. However, this consent should be properly documented and authenticated within 24 hours. 

For instance, if the patient’s son could have been reached within a very brief timeframe, such as less than four minutes, and his telephonic approval obtained, the medical team could have proceeded with the ventilator placement. In the scenario presented, the son was not immediately available, and the caregiver brought the patient without a comprehensive medical history. In such situations, the emergency department’s primary responsibility is to save the patient’s life, and they execute this duty appropriately.

In these critical moments, healthcare professionals do not have the luxury of assessing financial considerations, patient backgrounds, or preferences. The focus is solely on the patient’s immediate medical needs, which, in this case, involves addressing severe hypoxia.

However, after the patient was placed on the ventilator, there was an opportunity for the son to speak with the doctor and gain a better understanding of the situation. Unfortunately, this conversation did not take place until the following day, when the patient was already stabilized. Criticizing the medical team’s actions at that point is not warranted, as their actions were under Indian law.

Therefore, emergency care with informed consent can proceed, but withdrawing life support or making significant changes in care over the phone is not permissible. Such decisions require a more comprehensive legal process, involving the institution’s Ethics Committee and a legal representative to assess the patient’s wishes and capacity to provide informed consent. The patient’s opinion takes precedence, as they sought help in distress in the emergency department. The medical team’s priority is stabilizing the patient’s condition in such situations.

Dr. Kaushik

What is the significance of conducting a social assessment of the elderly population and its potential implications? Additionally, are there any formal training programs to address these social issues effectively?

In connection with this specific case, it’s important to address the importance of conducting a Comprehensive Geriatric Assessment (CGA), focusing on social factors and their implications. Human connection is a fundamental need and desire, and the absence of social connection can lead to loneliness, triggering various adverse outcomes, including inflammation, accelerated aging, muscular issues, and even suicidal tendencies. This underscores the significance of assessing the social well-being of elderly individuals. The assessment of socioeconomic status is an integral component of geriatric assessment. Failing to evaluate the socioeconomic status of an elderly patient can leave gaps in managing undernutrition, which is a critical concern in elder care. Now, let’s consider the key areas within the realm of social assessment. Firstly, the role of the patient is paramount. 

Firstly, the role of the patient is paramount. It’s essential to understand their unique circumstances, including their significant life events, interactions with support networks, and their financial status. Socioeconomic assessment also encompasses their position within the broader community, taking into account both local and international contexts.

When conducting home visits, assessing the patient’s living environment is crucial. This involves evaluating their family dynamics, relationships within the household, and the overall quality of their home environment. Additionally, it’s essential to gauge whether the patient is involved in social connections, as isolation can be detrimental to their well-being.

Elder abuse is a sensitive issue that may be concealed in the presence of a caregiver. Therefore, caregivers must handle such situations diplomatically. In addition to assessing the patient’s condition, caregivers play a role in counseling both the patient and their family members. They can also advise on using technical devices, such as social media, to enhance social connections. Caregivers often assume a significant role in the patient’s life, sometimes akin to a close relative, as seen in this particular case.

Sister Janet

What specific aspects require specialized training, and is the implementation of a formal geriatric nursing care training program recommended? If so, how can we establish such a program?

Certainly, geriatric nursing care indeed requires specialized training. With more than two decades of experience in nursing education, it is evident that while nursing education covers various aspects, including procedural demonstrations and advanced nursing practices, the emphasis on elderly care is often limited. Most nursing programs primarily focus on adult nursing care, and specific geriatric care tends to be addressed superficially.

The implementation of a formal geriatric nursing training program is increasingly necessary in today’s healthcare landscape. Such a program need not be post-graduate or require accreditation by nursing councils. Instead, it can be initiated at various institutions and hospitals, providing specialized training in geriatric care. This is particularly essential because the elderly population has unique needs, from sensory changes to mobility challenges, which necessitate distinct care approaches.

The training program should encompass various aspects, such as comprehensive assessments, medication management, social support, and caregiver assistance. The physiology of aging differs significantly from that of adults, and healthcare professionals need to be equipped with the knowledge and skills to address these changes effectively.

Elderly individuals often rely on external support, both physically and emotionally, making it crucial to incorporate memory care and emotional well-being into the training. In summary, specific, well-structured geriatric nursing training is highly advisable and should be considered an essential component of nursing education and professional development in the healthcare sector.

Shila MS

What is the current perspective on how doctors treat our nursing staff and what we have to do in the hospital?

The caregiver appears to be the most overlooked figure in this entire scenario, with their importance often disregarded. Especially in cases where the caregiver is a woman, as in this particular instance, their role is frequently downplayed. When the caregiver is hired through an agency, the psychological burden on them may be relatively lower, as they have no personal connection to the patient.

However, when a family member, such as a daughter, assumes the role of caregiver, the burden can be exceptionally high. In such situations, the daughter not only bears the responsibility of providing financial support, as the son does in the case mentioned but also takes on the primary decision-making role. This can lead to increased stress and the potential for critical comments from other family members.

It’s essential to recognize that caregivers have their own families, including husbands, children, and in-laws. When they are also caring for elderly relatives, such as their mother-in-law, who may be in their 80s, they face a complex juggling act. They cannot simply abandon their family responsibilities, and their situation becomes even more challenging if they are employed elsewhere.

The social setup and support system play a crucial role in such cases. If there are siblings or other family members who can temporarily step in to assist, the caregiver can better manage their responsibilities, make necessary arrangements, and attend to both the patient and their own family needs. This becomes even more complicated if the patient and caregiver live in different cities.

In conclusion, it’s vital to acknowledge the significant burden placed on caregivers, particularly when they are family members, and to provide them with the respect and consideration they deserve in society. The challenges they face are substantial and warrant recognition and support.

Dr. Pretesh

What is the significance of community geriatricians and their role in decreasing hospital admissions in this scenario? Do you think, as a community geriatrician, the line of management and planning would have been different? 

Understanding and examining the concept of “community geriatricians” is important when we refer to a community geriatrician, it doesn’t necessarily pertain to a healthcare professional solely working within the community. Instead, it encompasses any physician who comes into contact with the patient before their admission to the hospital. 

Several crucial aspects require attention in these discussions. Firstly, the concept of “multimorbidity” should be communicated, highlighting the presence of multiple health conditions in older patients. Additionally, the issue of “polypharmacy” and the potential risks associated with prescribing multiple medications should be emphasized. Furthermore, the aspect of “non-adherence to medications” warrants discussion, even though it might not receive adequate attention.

Moreover, it’s essential to consider the patient’s financial situation and affordability. In this particular case, while the patient’s son resides in the US, we must not make assumptions about their financial circumstances. The son’s profession and financial capacity should be assessed as part of the overall support system. This is crucial, especially when considering the substantial cost of medical treatment.

Assessing the familial support system is equally important. The geriatrician should identify family members who will be involved in decisions regarding the patient’s condition. Additionally, it’s necessary to evaluate available social support mechanisms, including friends, well-wishers, insurance systems, and neighbors. These elements play a significant role in the patient’s care and well-being. Psychosocial issues need to be addressed as well. Patients, especially older individuals, should have autonomy and decision-making power regarding their medical interventions. Advance directives should be considered and their wishes respected. In some cases, family members may collectively express the patient’s preferences, particularly when it comes to end-of-life decisions.

Effective communication is paramount in dealing with patients and their families. This principle should be ingrained in every geriatrician and physician caring for older individuals in the community. Accommodating the wishes of patients and their families is essential.

Lastly, close follow-up is vital. When patients provide specific directives, such as limiting the duration of intubation to prevent inconvenience to their families, healthcare providers must ensure these directives are honoured and acted upon.

Is it customary to address social issues, and do you maintain a record of such discussions? This practice can be valuable, particularly when patients arrive at the hospital in emergencies. Is there a process in place for them to reach out to you under such circumstances?

Certainly. We have a service known as “home health service” that caters to a significant number of elderly individuals who, due to their health condition, are unable to visit the hospital. Many of them are bedridden or confined to their homes. 

While some of these individuals are cognitively sound, they may lack the ability to visit the hospital or formally communicate their preferences regarding advanced directives with a legal representative.

In such cases, we do engage in discussions regarding advanced directives. Some of these individuals may have documented their preferences in writing or have conveyed them to their physicians well in advance. They may express their desire not to undergo any form of advanced medical intervention. These discussions and preparations allow them to make their wishes known and ensure that their medical care aligns with their preferences. This process takes into account the unique challenges faced by bedbound or home-bound elderly individuals, particularly those who may be unable to visit the hospital for advanced directives. 

Could you provide some key points on the topic of geriatric palliative care?

To begin, it’s essential to acknowledge that many healthcare professionals may not have a comprehensive understanding of the term “palliative care.” There is a common misconception that palliative care is primarily about allowing a patient to pass away peacefully. However, palliative care should be a continuous form of care that older patients receive from the very outset and throughout their life journey. It should address a wide range of issues, encompassing social, psychological, physical, and other factors that impact the patient’s well-being. Simply addressing the patient’s physical symptoms is insufficient for providing true comfort. 

To ensure the patient’s peace of mind and holistic well-being, it is vital to not only treat physical symptoms but also provide symptomatic relief, and address psychological issues, social concerns, and even spiritual matters. This approach helps patients feel at ease and understand the goals of their care. Palliative care organizations focus on making the patient as comfortable as possible within the shortest time frame.

In geriatric palliative care, the situation is less straightforward compared to cancer palliative care, which has clear guidelines and regulations. In cancer palliative care, patients often have advanced directives and it’s relatively easier to make decisions about withholding certain interventions when the patient’s life expectancy is limited to less than six months. In geriatric palliative care, the disease may be incurable, yet patients with conditions like dementia can live for many years. This complexity arises from a diverse group of elderly patients with varying conditions, such as end-stage lung, kidney, or heart disease, as well as neurological disorders.

The goals of geriatric palliative care depend on the individual patient and their family. For some, life extension, even in a bedridden state, is meaningful and important to the family’s happiness. 

In contrast, for patients who lack social support and have cognitive and physical impairments, the focus may shift to symptom control and pain management. The goal should align with the patient’s and family’s wishes in each unique case. 

The concept of geriatric palliative care has gained significance due to the increasing availability of medical interventions, like dialysis. However, India lacks structured training for geriatric palliative care. This gap led to the establishment of courses to sensitize healthcare professionals to the needs of geriatric patients. These courses aim to impart a palliative care approach to geriatric patients, facilitating better care for them.

Therefore, palliative care is a comprehensive approach that extends from the beginning to the end of an older patient’s life. It encompasses physical, psychological, social, and spiritual aspects. The goals of geriatric palliative care should be tailored to the individual patient and their family’s needs. Training in geriatric palliative care is crucial, and efforts have been made to bridge this gap in India by offering courses to sensitize healthcare professionals to the unique needs of geriatric patients.

Dr Kaushik

Is there any home-based training available to address the social aspects that you haven’t mentioned yet? While various applications can be connected to APICE, do we currently have any in place?

Let’s assess the current status of home-based training. In India’s healthcare delivery system, we have a multi-faceted landscape, which includes government-level healthcare services, private healthcare providers, as well as contributions from private agencies, NGOs, and individuals. However, geriatric care or elderly care is notably absent from the primary healthcare elements, despite its pressing need. The Decade of Healthy Ageing, initiated last year, emphasizes intergenerational bonding, primary healthcare, and preventive care. However, it has not yet integrated geriatric care into the primary healthcare system. 

At the grassroots level, we have government-employed community health workers known as Asha workers, who regularly collect health information, record it, distribute medicines, and provide counseling. The question arises: Have these Asha workers received training in geriatric care? Such training could significantly impact home-based care in India.

In India, some corporate entities have ventured into providing home-based healthcare services. However, many of these services rely on partially trained or untrained individuals, primarily driven by profit motives. This creates concerns regarding the quality of care and the potential exploitation of vulnerable individuals.

On a more organized front, the Geriatric Society of India has taken steps to address this issue. They have launched an online, pre-recorded video training program, which reaches participants from across the country. Additionally, the Genetics Society of India, in collaboration with the West Bengal government, introduced an online learning program in March of last year, focusing on geriatric care. Furthermore, the Ministry of Social Justice and Employment has initiated online and offline training programs for digital artisans, though the impact in terms of participants is still relatively modest compared to the demand.

The key challenge remains the insufficient number of individuals engaging in these training programs compared to the growing requirement for geriatric care expertise. As a response, a concerted effort is needed to intensify the promotion and accessibility of these training programs at all levels. The aim should be to bridge the existing gap and enhance the availability of trained personnel in geriatric care to better address the needs of elderly individuals in home-based care settings.

Sister Janet

As we are aware, nurse practitioners abroad play a crucial role in bridging the gap between patients, their families, primary care physicians, and hospitals. The question that arises is whether we, in India, are adequately prepared to train and incorporate nurse practitioners into our healthcare system, especially for the care of geriatric patients.

In developed Western healthcare systems, nurses play a significant role, and they have well-established professional independence. They are licensed to practice and often act as intermediaries between patients, families, and healthcare providers. In India, the role of Nurse Practitioners (NPs) is gaining traction, particularly in areas like critical care nursing where there is a shortage of doctors. NPs in critical care nursing, however, are still in the early stages of development, and there are various challenges to be addressed, including legal protection and supervision.

When it comes to caring for the elderly, senior nurses can have a substantial impact in community or home care settings, addressing many of the needs of elderly patients. They can provide essential care, communicate with medical professionals, and manage procedures independently at home. However, the elderly often face abuse within their own homes, and it can be challenging to address this issue effectively. Educating the elderly about their rights and financial independence, especially in their 60s and 70s, is essential. They should be encouraged to maintain contact with their social circle and manage their finances. Abuse within the household is a complex issue that is difficult to combat directly. It often requires intervention from external sources, but efforts can be made to educate and empower the elderly. Additionally, caregivers who work with the elderly may also face abuse, and addressing their challenges is equally important.

Could you please provide insights into the role of community services, government schemes, and policies in establishing community geriatric programs that are multidisciplinary, addressing caregiver burden, elderly abuse prevention, and other related aspects?

There are several government programs and policies in India aimed at supporting older persons. The National Policy for Older Persons, initiated in 1999, outlines various components for the government to provide for older citizens. Additionally, the National Programme for the Health Care of the Elderly, launched in 2004, is designed to offer specialized healthcare services for individuals above 60 years of age.

However, this program hasn’t been fully implemented at the grassroots level, which includes primary health centers, where weekly clinics for older individuals and home-based care should be provided. Implementation of these programs at the village level is crucial for their effectiveness.

Regarding the rights of senior citizens, the Maintenance and Welfare of Parents and Senior Citizens Act addresses the responsibility of caregivers, such as children, to care for the elderly. Failure to do so can lead to legal consequences, including imprisonment, and senior citizens can seek legal redress if they face elder abuse or neglect.

There’s also an All India Elder Helpline (14567) to provide assistance and advice to senior citizens. Moreover, various insurance schemes, including Ayushman Bharat, offer medical coverage for senior citizens. Ayushman Bharat provides up to five lakhs of medical coverage for BPL families.

However, awareness among professionals and senior citizens about these schemes is essential. To set up community geriatric programs, St. John’s has initiated a variety of community services, such as rural clinics, old age homes, home health services, and social support centers. These programs aim to provide healthcare services, social support, and companionship to elderly individuals in rural areas. St. John’s encourages other organizations and individuals to consider similar community geriatric programs to make a positive impact on the well-being of senior citizens.

Conclusion

The discussions provide a comprehensive view of the multifaceted challenges and opportunities in geriatric care. Informed consent, palliative care, and the role of caregivers are central to addressing the unique needs of elderly patients. Training and awareness programs for healthcare professionals are vital to enhancing the quality of care provided. Community services, government schemes, and multidisciplinary programs play crucial roles in supporting elderly individuals and addressing caregiver burden and abuse. The collection underscores the importance of concerted efforts to ensure that elderly citizens receive the care, respect, and dignity they deserve in their later years.