I have previously suggested that we might reduce the number of elderly patients admitted to hospital ‘because it is safer’ if we, as healthcare professionals, had to go through a consent process with the patient explaining the risks.
Well, I’m suggesting a more radical approach now, elderly patients admitted in similar circumstances should now be placed in orange jumpsuits…yep, just like the ones you remember from pictures of Camp X-Ray at Guantanamo Bay. I accept that might seem a little excessive but please, just hear me out and then think, is it really that much of a stretch to compare the two?
1) These elderly patients are admitted not for what they have done but for what they might do.
They might fall down again; they might become confused; they might not be able to call for help, all reasons used to justify admission for safety. Whilst I accept that these risks are all valid concerns they are not, on their own, reason enough to mandate admission, particularly when balanced against the known risks of a hospital stay. However, the real conceit at the heart of this is that somehow we have decided that we can see the future, can predict what is likely to happen and are acting benevolently to prevent it. Removing someone’s freedom, even if we think it is for good, is a potentially dangerous and damaging action not just for the individual but for society as a whole and that should make us extremely wary. We have a standard of presumption of innocence in law yet when it comes to these patients they are found guilty on arrival and then sentenced, based on little more than supposition, rumour and guess work.
2) They are often held against their will.
Many of the patients who we admit for safety don’t want to be admitted when they come to us, they want to go back home. Sure, by the time we have brow beaten them in to accepting our level of risk taking and/or used emotional blackmail via relatives they agree but if we are truly honest with ourselves, this is not a full and freely given consent for admission. How do we get away with this, why don’t they object? It’s easy really, they don’t stand up to us because they physically can’t stand up to us. Other patients who disagree with a course of action can get up and leave, we’ve all had that happen, however, these patients can’t do that, they are trapped here with unrelenting noise, constant questioning, inadequate sleep and inconsistent access to food, water and toilet facilities. Even if they could normally mobilise at home we keep them in an unyielding environment, deny them their usual clothes, footwear, walking aids etc and leave them ‘to think about things’ until they give in. Compliance gained from someone trapped in a hopeless, hostile situation seems closer to a false confession than true informed consent.
3) They are denied due process.
There are good, legal processes in place that are designed to protect people from having their liberty removed. The Mental Capacity Act helps us assess who may struggle with making their own decisions and the Deprivation of Liberty Safeguards has strict criteria that need fulfilling before someone can be held against their will. In reality, however, we at best skirt around these rules and at worst blatantly ignore them. We claim ‘it’s an emergency’, ‘it’s in the patient’s best interests’ or ‘we don’t have the time/resources to go through this properly’ for as long as we can until either the patient gives up, they deteriorate so they now need, and accept, admission or we’ve had enough time to do what we wanted in the first place and they can leave with our blessing. Just because it works out in the end doesn’t mean it was the right thing to do. The reality is that we are never held to account for these actions because these patients are often vulnerable and don’t understand that they are being denied their rights. A huge conflict of interest exists as we are the ones supposed to explain to patients the very rights which they would use against us. We are supposed to act in their best interest but instead we act in our own and so they never get unhindered, unfettered access to their rights.
4) This is done because of inadequacies in other services.
Well, what other option do we have? The services that should be dealing with these people, that should be making sure they are safe, well monitored, well supported and stay out of trouble can’t cope: we have to put them somewhere safe whether they like it or not! So what we are saying is because the system is failing it is okay to dump our basic principles in the name of pragmatism? That seems a particularly slippery slope to stand upon. During such times of stress, times of fear, times when the odds are stacked against us we are tempted to do what is usually unthinkable but it is exactly at this point that we must fight those impulses, look to our better angels and stand for what we know to be right. Just because times are tough doesn’t mean we should forget who we are and what we stand for. Don’t become a monster just because you are up against one.
Are we really guilty of creating Guantanamo like wards? Perhaps I’ve stretched the reality of the situation a little too far but I don’t think I had to stretch it all that much. I genuinely appreciate the dilemma we face in emergency care currently and I can write about what we do because I’ve been guilty of doing it myself. However, we do need to think carefully about admitting elderly patients to hospital just because we feel it is a safer option than discharge back in to the community, and if a written consent form doesn’t make us stop and think more carefully, perhaps an orange jumpsuit might!