Elder Care In Hospital

Overview

If you have experienced a hospital stay, consider the impact on you, your family and relationships, work or income, your quality of life, routine and future plans.

Psychosocial aspects of being a hospitalized older patient present physical, emotional and psychological issues for each individual that will vary with unique life circumstances.

In many hospital settings, the social worker will assess the patient, speak with family and review the patient’s psychosocial history with the team. Without a social work assessment, team members must become aware of the patient beyond the physical diagnosis.

Learning About the Person

Whether you have a formal social work assessment or not, consider these questions to learn more about the patient as a person.

Who is the patient?

  • What is the patient’s name (proper pronunciation)?
    • Is there a different name or nickname they prefer? 
    • How do they prefer to be addressed (e.g. Mr. Smith or Tom)?
  • Are they married, widowed or divorced?
  • Are they local or from out of town?
  • Are they employed or retired?
  • Will their health and/or hospitalization impact their income or financial obligations?
  • Are they a caregiver? Is someone dependent on them?
  • Are they engaged in activities in the community?

Why is the patient in hospital?

  • Has the patient been in hospital before?
  • Where were they hospitalized?
  • What was their experience?
  • Were they brought in by Emergency Health Services (EHS)?
  • Does the family know what is happening with the patient’s current hospitalization?
  • Did the patient receive a clear and factual explanation about their health condition and proposed treatment from a health care professional?
  • Have they researched their condition online realizing that all information that they find may not be reliable?
  • What do they understand about any condition-related information they’ve found on their own?

Does the patient have family or other support?

Family or a close friend can offer valuable assistance as a spokesperson and advocate for patients who are unable to understand or manage circumstances well.

  • Who is important to the patient? spouse/partner? child? friend?
  • Are difficult family dynamics present?
  • Who will be their advocate if the patient is unable to articulate their needs?
  • Will family be available to assist them when leaving hospital and with needs at home?

Does the patient have a Personal Directive?

  • Does the individual have capacity? Is the patient able to make informed decisions about health care procedures?
  • Is a delegate available to reassure the patient if necessary?

A Personal Directive is a witnessed legal document in Nova Scotia which any individual can create that names a delegate or health advocate to speak for them when they are unable to make their wishes known. Cognitive or issues affecting speech, language or hearing may require someone to speak on the patient’s behalf

Without a Personal Directive, a Substitute Decision Maker must be appointed from a list determined by the Department of Health and Wellness. For further information please see the Nova Scotia Department of Justice website.

Communicating with the Patient

The older patient, possibly with hearing loss, memory difficulties or more advanced cognitive loss, requires patience and a calm clear voice when you speak.

Introduce yourself and make eye contact. Explain your role and why you need to talk with the patient or family member. Would the patient like to have family present for explanations?

Position yourself at the patient’s level. Standing above the patient creates a power imbalance. Assure the patient that you are listening. Repeat back what you’ve heard the patient say if you are unsure of what the patient is communicating. Ask the patient if they have any questions.

Speak respectfully, in a kind manner. Take your time, explain information and respond to questions. This will help to enhance patient understanding and compliance. Some patients may have difficulty hearing or understanding. Make sure you speak to the patient even if you have to engage a family member, friend or other support in the conversation.

People value their dignity. You can make sure individuals maintain a sense of autonomy, independence, and self-confidence by treating the patient with respect. Older persons may feel marginalized because of their own attitudes or previous treatment by others due to advancing age or ageism/age discrimination.

Offer friendly and reassuring support whenever possible. Personnel in a hospital may forget that the building and activities of a large health care organization are unknown or confusing to people who have not worked in or frequented the environment. Taking the time to properly and clearly explain a procedure or directions can empower the patient and put them at ease.

Think about the terminology you use. Does the patient understand you? Are you using simple, non-medical terminology to help the patient clearly understand the issues?

Can the patient hear you? Do they require hearing aids? Are the batteries working? Do they read lips? Do you need a visual aid to help with understanding (e.g, a white board or tablet)?

Consider language barriers and respect cultural practices. In our diverse and changing society, particularly in larger communities, we encounter a variety of people. Ask about holidays, practices, etc. that may impact the patient's care. Staff must become familiar with resources available for suitable interpretation or translation in their facility. Seek interpreter or translator help from organizational supports

Patients have a lot to adjust to when hospitalized. In an environment where the patient may feel intimidated by those in authority, or overwhelmed by the activities and unit procedures, the individual requires a sense of control and acknowledgement. The patient may experience fears and concerns for their ongoing obligations in the home or community, or be worried about their health and wellbeing. Many factors can cause distress including:

  • Loss of privacy
  • Constant stream of new faces
  • Loss of sense of dignity
  • Being unaware of the schedule for the day and/or upcoming investigations

In addition to not feeling well or experiencing pain, life is disrupted and foreign in hospital. Having difficulty sleeping because of roommates or unfamiliar sounds can be difficult. Patients may be understandably anxious when the lighting is different, when they must use a shared bathroom and the food is not the same as home. The older individual with cognitive decline/loss may be impacted more dramatically when their ability to appreciate the situation and their altered perceptions impact their well-being.

Use clear language about bodily functions and types of undergarments. Perform frequent checks and changes. Whenever possible, offer toileting or scheduled toileting to lessen the indignity of this experience. Incontinence can rob a person of their sense of dignity. Bodily functions that the individual usually controls throughout adulthood can be lost due to illness or simply advancing age. The use of protective undergarments or pull-ups is frequently regarded by the older person as degrading, particularly if referred to as diapers.

Additional Considerations

Discharge

Leaving a health care facility following any admission, procedure, and/or surgery can be a time of uncertainty. Assure the patient they can ask questions and will be heard.

Pressures to admit and discharge patients efficiently are growing with an increasing older population. A good discharge plan can help to promote recovery, prevent stress and avoid return visits to the physician and emergency department.

Gather this info: How will the patient return home? Is family able to assist? Are there financial concerns? Who will make meals, buy groceries, help with household tasks? Are there any additional issues?  Community supports? Home care info? Equipment? Follow-up appointments? Medications?

Serious Illness & Death 

When the patient is unexpectedly ill due to accident, stroke or other significant health issue, patient and family require compassion and understanding to process the diagnosis and consequences. The need to carefully explain, repeat and reinforce your information is necessary as emotions can cloud thinking and memory. Having an additional person present during the meeting for support and clarification of the explanation should be offered.

Discussions about death can be very challenging, especially when it is unexpected. For staff who see their role as saving and maintaining life, dealing with death and grief can be difficult but the need for support and acceptance is vital.

Consider: Is the patient involved with church or religious beliefs? Should the hospital chaplain or religious representative be contacted? Can information be provided regarding hospice or palliative care? home care support? funeral arrangements? grief support?

References

Admi, H., Shadmi, E., Baruch, H., & Zisberg, A. (2015). From research to reality: minimizing the effects of hospitalization on older adults. Rambam Maimonides medical journal, 6(2), 1-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422456/

Hominick, K., McLeod, V., & Rockwood, K. (2016). Characteristics of older adults admitted to hospital versus those discharged home, in emergency department patients referred to internal medicine. Canadian Geriatrics Journal, 19(1), 9-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4815936/

Karki, S., Bhatta, D. N., & Aryal, U. R. (2015). Older people’s perspectives on an elderly-friendly hospital environment: an exploratory study. Risk management and healthcare policy, 8, 81-89. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4440357/

Singh, I. (2016). Assessment and management of older people in the general hospital setting. In Challenges in Elder Care. IntechOpen. https://www.intechopen.com/books/challenges-in-elder-care/assessment-and-management-of-older-people-in-the-general-hospital-setting