Introduction

The behavior of every healthcare professional should be based on the basic principles of ethics, which are dominated by the effort to always act in the best interests of the patient. However, the rapid development of medicine, technology and pharmacology has changed the outlook on this effort, which has a negative impact on the provision of care for chronically ill and geriatric patients (Masár, Fedorová, Hudáčková, 2014). Many ethical issues can arise in the care of the elderly. They are most often related to ethical principles and the underestimation of seniors in terms of age (ageism). Important ethical issues include the deprivation of autonomy in patients with cognitive impairment or the care of a dying senior, especially in an institutional facility (Poledníková, 2013).

The goals for the ethical provision of health care to seniors are equality in diagnosis and treatment, availability of professional care, ensuring the autonomy of seniors, the right to a dignified death. The goals help to achieve the principles of access to the elderly in treatment that health professionals should follow. The principles include:

  • raise the care of the senior/geriatric patient to a primary interest, - act politely and considerately,
  • respect dignity and privacy,
  • listen to the senior/geriatric patient and respect their opinions,
  • provide information in an understandable form,
  • respect the right to co-decide on treatment,
  • increase your professional knowledge and skills,
  • insist that prejudices do not affect health care,
  • avoid abuse of the position of a medical professional,
  • work for the benefit of the senior/geriatric patient (Nemčeková, 2008, Krajčík, 2014).

Basic ethical principles and the geriatric patient

The basic ethical principles include beneficence, nonmaleficiency, autonomy and justice. In the case of seniors, even in conjunction with their specificity related to treatment, the course of diseases and changes in the aging process, their compliance can be problematic.

  1. Beneficiencia/usefulness (salus aegroti suprema lex). Synonyms include protection of life (prevention, rescue), restoration of health (treatment, care), improvement of quality of life, relief from suffering and pain. In practice, this means that the doctor and the nurse must act for the benefit of the patient and look for the best treatment procedure, the best care solution for him (Nemčeková, 2008). The most frequent problems with non-compliance are related to pharmacological treatment. The senior is prescribed medicine due to the disease, not age, the medicine is unsuitable for the senior, it has an incorrect dosage and due to polypharmacy, the risk of drug interactions also increases. The second serious problem is insufficient treatment strategies, especially in the therapy of oncological diseases. A non-standard approach to the treatment of malignancies results in an increase in the mortality of seniors. The results of clinical studies confirm insufficient treatment activities for elderly patients. The treatment of geriatric oncology patients should therefore begin with an estimate of life expectancy, an assessment of the overall condition and a discussion of its benefits and risks (Wagnerová, 2020). Beneficence is often not accepted when caring for the terminally ill in institutional facilities. Here we encounter ethical dilemmas of which care a terminally ill senior will benefit from and which will not. The most common is the administration of artificial enteral nutrition and fluids (St Ledger, et al 2021).
  2. Nonmaleficiencia - never harm (primum non nocere), not creating risks, minimizing possible risks. Not to harm the physical, psychological, social (socio-cultural) and spiritual side of a human being. In elderly care, this means considering the harmful consequences that healthcare professionals' actions could have on the patient. A large number of medicines are harmful to seniors, frail seniors are also at risk, and many times inappropriate communication can also be harmful. When communication is conducted in an inappropriate way, the need for self-expression and self-development of seniors is disturbed. An inappropriate way of interaction is communication invasion and deprivation. In a communication invasion, something is imposed on a senior that he does not want or ask for. In case of communication deprivation, the senior is not allowed to communicate (Čižmárikova, 2019).
  3. Autonomy (voluntas aegroty suprema lex) - the patient has the right to self-determination, he can intervene in the treatment process. Informed and free decision, participation in decision-making processes (Informed consent / informed refusal). Correct assessment of the degree of ability or incapacity in decision-making is important for seniors. The patient should understand, distinguish, consider all possible alternatives, have an adequate level of receiving information, freely make a decision without external pressure or coercion. He has the right to decide on future care (Kutnohorská, 2007). Respecting the wishes of the patient. During inpatient treatment, the right to information and adequate access, explanation of the course of the intervention, information about rights and obligations during hospitalization. In practice, however, I encounter the fact that the senior cannot intervene in the treatment process, he is not sufficiently informed. Acceptance of the patient's decision in palliative care is also a problem. The doctor must be ready to listen and the patient to talk about his feelings, desires and reasons for his decision. On the other hand, the patient should have the opportunity to think about whether his decisions in the terminal stage are compatible with his life attitude, or whether his decisions are influenced by fear and therefore can be called inauthentic - family and close people can help him here (Podgorica, 2020).
  4. Justice (iustitia) – not to discriminate, justice in the distribution of scarce materials, who will be given a special kind of treatment (Németh, 2009; Krajčík, 2014). Underestimation related to age and health (Rosin, Dijk, 2005). It can often be a manifestation of ageism on the part of healthcare workers (Nemčeková, 2008; Šoltés, Pullmann, 2008). Contraindication of some procedures due to age. In old age and frailty, the availability of health care, including medical care, must not be limited. Age is not a criterion for changing the medical approach (Wagnerova, 2020, p. 420).

Acceptance of basic ethical principles in the care of seniors - results of mixed research

The research took place during 2020 and the first half of 2021. At the beginning of the research, we implemented a pilot study in selected departments and clinics in the Central Military Hospital of the SNP Ružomberok-FN. Subsequently, we continuously analyzed the documents (research studies and review works) obtained in scientific databases.

The main goal of the research was to find out how the basic ethical principles in the care of seniors are observed in practice.

Sub-goals:

  1. To find out in which area of care for the elderly the ethical principles are most often violated.
  2. To find out what ethical problems most often occur in the care of the elderly.
  3. To find out how the current situation in the health sector affects the observance of ethical principles.

Research Methods

The main method was narrative review, during which we analyzed documents during the year. We focused on research reports, scientific articles that were available in the databases Scopus, Web of Science, PubMed Central and published in the years 2005-2021. We selected the documents after entering keywords - ethical principles in geriatrics, ethical principles in the implementation of care for geriatric patients, ethical issues in the care of the elderly.

An additional method was a self-constructed questionnaire. The questionnaire was administered in January and February 2020 and was part of a pilot study.

Research File

In the pilot study, the research group was nurses who provided nursing care to the elderly. They were nurses working at the Department of Internal Medicine, the Neurology Clinic, the Department of Radiation and Clinical Oncology, and the recovery department. Inclusive inclusion criteria were willingness to fill out a questionnaire, experience in caring for seniors and geriatric patients, knowledge of nursing ethics. A total of 60 nurses (57 women and 3 men) participated in the study. The average age of the nurses was 33 years. The research file in the narrative review was documents retrieved using keywords. In total, we worked with 116 scientific studies.

Results

First, we present the results of the pilot study. In the individual items of the questionnaire, we collected data that helped us in evaluating the goals. The questions were divided into three areas: 1. occurrence of ethical problems in the care of seniors, 2. acceptance of ethical principles and 3. occurrence of age discrimination in institutional facilities.

Area 1 In area 1, the questions were focused on the most common ethical problems, their frequency of occurrence, and the identification of health workers whose interventions and attitudes most often arise.

Table 1 shows the results we obtained from the nurses' answers to the question: What ethical problems that affect the care of the elderly do you encounter at the clinic/department where you work?

Tab. 1 Occurrence of ethical problems affecting the care of the elderly

For this item, the nurses marked several alternatives. The alternative with the largest number of markings (55) was number 6 inappropriate addressing of seniors. Among the other most frequently appearing ethical problems was the contraindication of some procedures - 50 nurses. 45 nurses mentioned inadequate decision-making competence as an ethical problem.

For the item focused on the occurrence of problems, the nurses stated the frequency of occurrence at least once a week.

To the question: Who among the category of health workers most often violates ethical principles, the nurses answered that it is most often sanitary workers and medical assistants. Table 2 presents the answers in numbers.

Tab.2 Categories of healthcare workers and violation of ethical principles

Area 2 The second area was focused on ethical principles. Here we included questions that related to ethical principles in general, but we also investigated the causes of their violation.

After evaluating this area and the individual items, we found that nurses and other health workers have knowledge of basic ethical principles, they know about their differences when providing individual care to seniors, but they also noted that they are often violated - Table 3.

Tab. 3 Violation of ethical principles

As can be seen from Table 3, the principle of justice is most often violated in the investigated facilities - 43 respondents and autonomy, which was indicated by 17 nurses. Only 3 stated that the do no harm principle was violated at their workplace.

Area 3 Age discrimination can also be one of the causes of violation of ethical principles, therefore the last area was focused on the occurrence of ageism and its forms in institutional facilities. In the questions, we focused on the occurrence of age discrimination and individual forms of ageism. We found that only 8 nurses think that healthcare professionals have a negative attitude towards older people and underestimate them in terms of age. They also positively stated (up to 57 nurses) that seniors are provided with adequate health care. In response to the control question: Do you think that healthcare is provided to the same extent to hospitalized seniors as to younger patients?, even 59 nurses gave a positive answer. When asked whether medical care was not provided to the senior in terms of his age, they similarly indicated a desirable answer. They stated as the reason for not providing care or therapeutic intervention: the wishes of the geriatric patient or his family.

Results of narrative review

As we already mentioned in the introduction, during the years 2020-2021, we gradually analyzed scientific studies focused on the investigated problem. We devoted ourselves to original scientific works, observational studies, but also overview works. We compared the results in terms of publication date. When did we find out what problems in compliance with ethical principles were solved in the respective years of publication - Table 4.

Tab. 4 Most frequently unaccepted ethical principles in published works

As the table shows, we evaluated the results qualitatively. In the documents, we focused on the term ethical principle and its non-compliance in clinical practice. Most scientific outputs were devoted to the violation of the autonomy of the geriatric patient. Then there were differences in terms of period. In the first period until 2010, studies were also devoted to the principle of doing no harm. In the second period, studies focused on the benefits of treatment in geriatric patients. In the last period, and above all, the works from 2020-2021 were focused on accepting the principle of justice, especially in the treatment of seniors with COVID 19.

When working with documents, we also compared in which area or with which type of care there is most often a problem with accepting ethical principles or ethical dilemmas arise.

Most of the publications that considered the benefit of care for the benefit of the geriatric patient were thematically focused on the end of life, terminal care. They were treatment dilemmas - the application of nutrition, hydration, opiates. The authors focused on the dignity and benefit of care, resuscitation or the patient's decision not to resuscitate, and invasive procedures.

The second important area was competence and assessment of competence in decision-making about treatment in geronto-psychiatric patients - autonomy, informed consent, understanding of information.

Other topics included pharmacological treatment, providing diagnostic and therapeutic interventions to seniors, long-term care, geriatric frailty and ageism. Table 5 shows individual topics that were most often the subject of research and meta-analyses. They are listed from the most processed and described to the least processed areas.

Tab. 5 Areas of treatment or care where ethical principles are not accepted

Discussion

In the care of the elderly, many ethical problems arise and are present, which can affect, disrupt and in a certain way even make the care of the elderly difficult. The most frequently occurring ones include: impaired decision-making competence, contraindications for certain procedures due to age, disrespect of the patient's will, prejudices against seniors, discrepancy in the use of funds for treatment due to age, loss of identity and individuality of an old person in institutional treatment (Poledníková, 2013; Rapčíková, Janiczeková, 2018). It helps to eliminate the mentioned facts if health workers do not forget a humane approach, respect for the dignity of the patient and observe basic ethical principles (Podgorica, 2020; Tampi, 2018; Tokovská, 2010).

Also, the main goal of the conducted research was to find out how the basic ethical principles in the care of seniors are observed in practice. Using methodological triangulation, we analyzed the obtained results. When evaluating the pilot study, we found that the principle of justice and autonomy is most often not observed in institutional care. According to the results of the narrative review, it was primarily the principle of autonomy and subsequently it was the principle of justice and do no harm. The principle of autonomy and its disruption is associated in the scientific literature with the topic of end-of-life care and care for patients with cognitive impairments. In the study by Martinéz et al (2020), it is stated that for the autonomy of terminally ill seniors and their family members, comprehensive guidelines are important, as well as care focused on the individual needs of seniors. Rees, King, Schmitz (2009) recommend having enough resources (material, financial), developing ethical education of employees and having space for ethical discussion of individual members of the multidisciplinary team.

Through quantitative and qualitative analysis, we also obtained answers to sub-goals. The first sub-goal was to find out in which area of ​​care for the elderly the ethical principles are most often violated. Through a pilot study, we tried to find out the areas of violation of ethical principles in institutional health care. In clinics that provided acute care, it was mainly the implementation of diagnostic and therapeutic interventions. In the subacute care unit, excessive care of the dying. In the original scientific papers and meta-analyses, it was the area of ​​long-term care, most often in nursing homes and the area of ​​care for the dying. Bollig (2015) pointed out that in nursing homes and long-term care, it is important to ensure that care optimizes the risk-benefit ratio in all interventions, respecting the individual's right to make free and autonomous decisions, protecting privacy and protecting the most vulnerable people, and ensuring an equitable distribution of resources. Integrated care is essential for long-term care in the home environment. Because for persons with disabilities, in terms of reduced mobility and orientation skills, the provision of health and social care in one place is an advantage. The separation of health, social and other services, their location in different places, puts elderly people at a disadvantage and it is often impossible for them to visit them, the quality of care decreases.

The second goal was to find out what ethical problems most often occur in the care of the elderly. It emerged from the nurses' answers that they are associated with inappropriate social communication - for example inappropriate addressing of seniors. Among the other most frequently appearing ethical problems were the contraindications of certain procedures and inadequate decision-making competence. In scientific studies, it was prejudice against seniors, ageism. The main ethical issues were related to the autonomy of older people, respect for their needs, wishes and values ​​and respect for their decision-making. They covered patients' rights, the rights of the elderly, the use of advance directives, ethical dilemmas of treatment, nutrition and autonomy. According to Tokovská (2011), staff in long-term care facilities, due to problems with financial evaluation, low social status, overload... "forget" basic ethical principles in their daily routine.

The last goal was to find out how the current situation in healthcare affects the observance of ethical principles. We obtained the answers only through a qualitative analysis of studies that were published between 2016 and 2021. They mostly focused on ethical principles in the care of the elderly and specific problems in the care of terminally ill seniors. These were, for example, issues of substitute decision-making, withdrawal and withholding of interventions, use of cardiopulmonary resuscitation and do-not-resuscitate orders, responding to requests for intervention, allocation of health care resources. A critical element of ethical care was recognizing and acting on the wishes of the older individual. In publications from 2020 and 2021, several studies looked at the application of ethical principles in the treatment of seniors with COVID 19. They noted that for people who already have COVID-19, healthcare workers may prioritize those who are likely to survive. However, deciding on the basis of chronological age alone is not justified; in addition to age, other aspects that determine the theoretical life expectancy must also be taken into account. Also Martinéz et al (2020) states that correct individualized prioritization in the allocation of limited resources is essential for clinical practice. However, discrimination based on sex, race or age has no role in prioritization unless it is clearly justified.

Conclusion

Health care does not only represent certain procedures and treatment methods, but also the approach of the medical staff, which has a great deal to do with how the patient feels, what he experiences and how his health condition develops. The quality of care and ensuring an adequate quality of life for an elderly patient is closely related to the observance of basic ethical principles. We were also convinced of this when conducting research. After evaluating the pilot study, we found that ethical problems appear quite often in connection with the care of the elderly. Medical personnel violate ethical principles, especially the principle of autonomy and justice. Therefore, it is very important to think about the causes of these problems and implement appropriate measures in a timely manner. Change can occur if health workers have an adequate number of patients, materials, equipment, time for adequate communication with seniors and family members.

Authors: PhDr. Katarína Zrubáková, PhD., PhDr. Mária Lehotská, PhD., Bc. Viktória Belancová Faculty of Health Sciences, Catholic University of Ružomberok

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