Keywords

17.1 Introduction

Health and social care professionals meet ethical dilemmas constantly. Being able to make clinical decisions based on sound ethical principles is central to compassionate care and should underpin all the topics covered in this book.

The range of consequences of fragility fractures include acute and chronic pain, loss of mobility, loss of independence, increased frailty and, for some, it may be the event that precipitates death. The decline in health, and wellbeing that often follows a fragility fracture threatens wellbeing, especially when we have limited capacity and/or diminished power over their own lives and decisions. These challenges make a person vulnerable because they may be unable to take care of themselves and/or to protect themselves from harm or exploitation. Needing to obtain assistance from family, friends, or other carers, places them at increased risk of various types of abuse.

Providing compassionate care to older people involves maintaining their dignity and autonomy. The ethical principle of autonomy supports the right of older adults to be empowered in their decision-making and to determine their own plan of care. This also extends to decision-making about end-of-life plans and care.

The aim of this chapter is to provide practitioners with information about ethical principles and dilemmas in caring for patients with fragility fractures so that they can provide ethically sensitive care, including at the end of life.

17.2 Learning Outcomes

At the end of the chapter, and following further study, the practitioner will be able to:

  • Explain the causes and consequences of vulnerability of individuals following fragility fracture.

  • Describe practitioners’ responsibilities in safeguarding vulnerable older adults from abuse.

  • Place dignity at the centre of care.

  • Identify threats to dignity in healthcare.

  • Explore ethical challenges at the end of life.

  • Engage in ethical decision-making.

17.3 Ethics in Providing Care for All Adults Following Fragility Fracture

The range of individual consequences of fragility fractures include chronic pain, loss of mobility, loss of independence, increased frailty and, for some, it may be the event that precipitates death. Such decline in health threatens a person’s wellbeing, especially in the absence of the capacity or resources to resist such a threat. Hip fracture, for example, is often cited as an injury that leads to poor health outcomes; about half of patients lose their prior level of physical function, and many lose their independence. Only around half those who have recovered from a hip fracture regain mobility, and often not to the same level as prior to the fracture. Many also report chronic pain 1 year after the fracture. However, hip fractures are not the only injuries that have a negative impact on individuals’ future lives: vertebral fractures are also associated with higher disability and mortality rates, even when they are asymptomatic [1].

Practitioners working with individuals following fragility fracture must frequently make decisions on behalf of their patients and balance different ethical perspectives. These decisions are guided by the principles of healthcare ethics: beneficence, non-maleficence, autonomy, and justice. These principles are defined in Table 17.1.

Table 17.1 The principal components of healthcare ethics (from Varkey 2021 [2])
Full size table

Healthcare workers are often faced with complex medical and moral situations. Many patients with fragility fractures are older adults, but it is essential not to assume that age is an indicator of function, capacity, or health status. Older people are, however, more likely to be vulnerable when they need health and social care; requiring specialised care which takes their age and function into account and ensures that principles of healthcare ethics are applied appropriately.

Clinical guidelines can be of limited use in these instances, so several ethical frameworks have been proposed to assist in decision-making processes. Ethical frameworks are analytical tools designed to assist healthcare workers in complex moral decision-making situations. Models and frameworks tend to share basic components. An example of some common fundamental questions a practitioner could ask when making ethical decisions is provided in Box 17.1.

Box 17.1 C.A.R.E. Questions for Ethical Dilemmas (Schneider and Snell 2000 [3])

  1. 1.

    What are my core beliefs, and how do they relate to this situation?

  2. 2.

    How have I acted in the past when faced with similar situations? What do I like about what I have done? What do I not like?

  3. 3.

    What are the reasoned opinions of others about similar situations? What does our culture seem to say about this situation?

  4. 4.

    What has been the experience of others in the past when faced with similar situations? What do I like about what they have done? What do I not like?

The questions in Box 17.1 can be applied, for example, to the case study in Box 17.2.

Box 17.2 Case Study Part 1: Ethical Principles

Mr. Kaur has just been admitted to hospital with a fragility hip fracture. It is immediately apparent to the nurse that he is thin and frail. The handover from the Emergency Department (ED) informed that he arrived by ambulance alone, his clothing and body smelled of urine, he seemed confused and disoriented, that he has a stage 3 pressure injury on his sacrum and the heel of his injured leg has a black/purple area under the skin (see Chap. 9). Mr. Kaur is 86 years old. The ambulance crew told the ED staff that he lives in the home of his son and his family. Mr. Kaur’s daughter-in-law called the ambulance but could not accompany him to the hospital. She told them that he is diabetic, has been “unwell” for a few weeks, and recently fell at home.

Consider:

  • Given the four principles of healthcare ethics described in Table 17.1—what concerns do you have about Mr. Kaur and his current state of health and wellbeing?

  • How can you begin to answer the questions in Box 17.1?

  • What further information do you need about Mr. Kaur’s social circumstances?

  • What are your priorities on his admission to hospital?

  • How might you act in Mr. Kaur’s best interests?

17.4 Dignity

Respecting dignity is a fundamental aspect of quality of life and a central principle in compassionate healthcare delivery. It involves respecting the uniqueness of each person by taking care of the whole person including social, psychological, and spiritual aspects of life as well as the physical ones [4]. Understanding the importance of dignity is crucial in influencing the caregiver’s view of humanity and quality of life and in providing compassionate care [5].

Preserving dignity involves respecting the uniqueness of each person and acknowledging that the world- or life view of health professionals and other caregivers can be very different from that of individuals in their care [4]. Human dignity is a moral code, a duty and a human right and, for care providers, a moral obligation to enable people to feel valued, grow, and develop. The International Council of Nursing Code [6] states that:

“Inherent in nursing is respect for human rights, including cultural rights, the right to life and choice, to dignity and to be treated with respect”.

The presence of chronic and acute health problems, injury, and reduction in self-care ability mean that there is often focus on medical needs, which can result in dehumanising of care, threatening an individual’s dignity. This places the protection of dignity at the centre of holistic individualised care.

All users of healthcare services have the right to be treated with dignity and respect. However, some older people can be particularly vulnerable to loss of dignity, so it is essential that extra attention is paid to making sure that care is provided with dignity at its centre. This involves care teams having a shared view of what dignity is and what it means to be treated as an individual. Dignity is a foundation on which many of the topics in this chapter should be considered, and it should be applied to all the chapters in this book.

Many older adults perceive dignity as central to the meaning of a good life in old age. Failure to maintain their dignity in both acute and long-term care facilities can lead to depression and even accelerate death [7]. Care with dignity supports the self-respect of the person, recognising their capacities and ambitions, and does nothing to undermine it [8] Dignified care assists individuals to maintain their individuality and to have it respected by others. While dignity itself can be a complex concept, it is often a collection of fundamental caregiving actions that can help to maintain it. For example:

  • Maintaining an individual’s privacy and confidentiality during caregiving

  • Offering information, choice, and respecting decisions

  • Assistance in fundamental aspects of care such as eating meals and access to lavatory/bathroom facilities

  • Addressing individuals appropriately

  • Enabling them to maintain their own personal standards such as a respectable appearance

  • Stimulation and a sense of purpose by supporting activities that are fulfilling.

17.5 Vulnerability

Vulnerability is a concept applied to individuals (or communities) who have impairments (social, psychological, and/or physical/physiological) that result in [9]:

  1. (a)

    compromised capacity to make decisions and/or are

  2. (b)

    at risk of incurring harm and/or being wronged

“Vulnerable adults” are often defined as those who have a restricted ability to give their consent (such as people with cognitive difficulties) or those who are biologically/physically vulnerable because of their health needs. This potentially decreases a person’s control over their own actions and decision-making [10]. In the context of fragility fracture care and prevention, vulnerability can be seen not only as a characteristic of an individual, but also a relationship between individuals and others. Vulnerability is often created by relationships where there is unequal power such as that which exists between a patient and those who provide their care. The presence of health and social care needs increases vulnerability. Ill health, frailty, and/or injury, for example, can lead to a greater reliance on others, increasing the demand for health and social care and additional responsibilities for families and informal caregivers [11, 12].

Vulnerability is a complex multidimensional construct involving behavioural, socio-cultural, economic, and political elements which interact with biological processes throughout life. In the presence of chronic and acute health conditions, vulnerability can be linked to factors such as negative self-perception, health deterioration, biological ageing, unhealthy lifestyle, frequent and prolonged hospitalisation, inability to access health services, poor knowledge of health threats, scarce financial resources, and inadequate social networks [13]. A vulnerable adult has limited self-care abilities and may be unable to protect themselves from harm or exploitation. There is significant risk to their health and wellbeing if assistance is not provided or the person is unable to access assistance and care from individuals or organisations. There is an association between vulnerability and factors which are common in patients with fragility fractures: age, female gender, low physical activity, presence of comorbidities, (such as hypertension, diabetes, osteoarthritis, osteoporosis) polypharmacy, and frailty [14]. A vulnerable individual can have four times the risk of death or functional decline when compared to older people not assessed as vulnerable.

The Vulnerable Elders Survey-13 (VES-13) is one of several validated tools available to screen patients for frailty and vulnerability. The components of the 13-item questionnaire include age, self-rated health, limitations in physical function, and disability. The VES-13 [15] provides a simple, function-based assessment that can help healthcare professionals to identify older people with increased vulnerability.

17.6 Decision-Making Capacity

As an element of the principle of autonomy, Capacity, or Decision-Making Capacity (DMC), refers to a person’s ability to assimilate and use information relevant to making a specific decision and use this information to make and communicate a choice. It is generally assumed that adults have the capacity to make decisions affecting their own lives. However, vulnerability through acute and chronic ill health, injury, and surgery can affect a person’s ability to make decisions and healthcare practitioners frequently need to make an assessment of that capacity so that they can judge if decisions need to be made on behalf of the person [16]. Capacity is required for a person to give consent to all healthcare interventions.

Various legal and ethical frameworks have been devised globally to assist in assessing capacity as well as making decisions on behalf of another person. These frameworks tend to involve the following or similar principles:

  1. 1.

    Decision-making capacity should always be assumed to be present unless there is a reason for concern. Concerns should lead to assessment of capacity.

  2. 2.

    Capacity is context-specific in that it relates to a specific decision being made at a specific time under specific circumstances.

  3. 3.

    A person should only be assessed as without capacity to make a decision once all possible actions to help them make decisions have been employed: this includes all aids to communication such as speech, sight and hearing, and translation if the person does not speak the same language as those providing care.

  4. 4.

    Capacity is fluctuating and can change from one decision-making even to the next—if a person lacks capacity and a decision is not essential, it should be delayed until they have capacity.

  5. 5.

    Decision-making must be based on accurate and timely information presented to the person in a manner that is easy for them to understand.

  6. 6.

    If someone has capacity, their decisions must be respected, no matter however unwise any decision is considered by others.

  7. 7.

    Knowing if and how a person has appointed someone to make decisions on their behalf (e.g. through “power of attorney”) is essential in supporting decision-making. Liaison with families and carers/caring organisations is central.

If an individual does not have capacity to make a decision, the decision should be delayed whenever possible unless they are unlikely to return to a state where they have capacity. If the person does not have capacity (either temporarily or permanently) or there is no legal power of attorney, healthcare staff may intervene on their behalf based on the principles of “best interests” decision-making using an interdisciplinary team approach. This may involve liaison with family and carers, but they should not be decision-makers unless they have legal written power of attorney to do so. Box 17.3 provides an opportunity to consider this in more detail in relation to the case study introduced in Box 17.2.

Box 17.3 Case Study Part 2: Capacity

It is now the day after his admission and Mr. Kaur’s hip fracture surgery has been delayed because he is receiving treatment for dehydration. He remains confused and disorientated and seems unable to communicate his wishes to the hospital staff. Once his dehydration has been resolved he will be scheduled for urgent surgery to manage his fracture and pain—this is planned for tomorrow. The nursing team have tried to contact his family to discuss Mr. Kaur’s care but have been unable to reach them. One of the issues with this is consent for the surgery.

Consider:

  • How could you ascertain Mr. Kaur’s capacity to make decisions and give consent for his surgery?

  • If assessment identifies Mr. Kaur lacks capacity now, what should the next steps be?

17.7 Safeguarding

Older adults with fragility fractures can be vulnerable to abuse. Health professionals’ recognition of and response to concerns about abuse play an important role in protecting people from further harm [17].

There are several different types of abuse which may be apparent to practitioners working with patients following fragility fractures. Abuse may have been part of the mechanism of injury for the fracture; for example, if an older person has fallen because of weakness due to neglect, lack of appropriate care and supervision, or violence against them.

The World Health Organization [18] defines abuse of older people as:

“… a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person”.

Such abuse constitutes a violation of human rights and respect and leads to loss of dignity for an older person. Abuse includes physical, sexual, psychological and emotional abuse, financial and material abuse, abandonment, and neglect. Abuse can lead to serious harm and even death. Older people suffering a fragility fracture may have experienced any and more than one of these types of abuse, but physical abuse and neglect are most likely to come to light following their injury.

Physical abuse includes pushing, hitting, slapping, kicking, misuse of medication, restraint, and withdrawal of freedom.

Neglect involves acts of omission which include omission or lack of care provision and failure to meet care needs or provide access to appropriate health and social care service, as well as not providing necessities such as adequate nutrition, fluids, and/or heating.

The perpetrators of any form of abuse can be anyone with power over the life of an older person, especially those who are in a position of trust or tasked with providing care such as family members’ caregivers.

Safeguarding vulnerable adults involves protecting an individual’s right to live in safety, free from abuse and neglect [19] and involves collaborative working to recognise risks and prevent abuse, while at the same time making sure that their safety and wellbeing are promoted. This includes ensuring individual wishes, views, feelings, and beliefs are incorporated into their care. Box 17.4 provides a case example.

Safeguarding duties seek to protect all adults who [20]:

  • Have needs for care and support (whether or not the local authority meets any of those needs)

  • Are experiencing, or at risk of, abuse or neglect

  • As a result of those care and support needs are unable to protect themselves from the risk of, or the experience of, abuse or neglect.

Box 17.4 Case Study Part 3: Vulnerability

Referring back to what you already know about Mr. Kaur from Boxes 17.2 and 17.3: it is now a few hours since he has been admitted to the hospital ward and you have been providing his care during this time. You have had an opportunity to make an assessment of his health and wellbeing. You have not yet heard anything from his family and have been unable to contact them so far.

Consider:

  • In what ways would you suggest Mr. Kaur might be perceived as being vulnerable?

  • What further information do you now wish to access about Mr. Kaur and where might you be able to access this information?

  • Do you have any safeguarding concerns? Are there any signs of intent to harm? Are there any signs of neglect?

  • With whom might you discuss your concerns given the information you have so far?

  • How will you approach a conversation with Mr. Kaur?

When there are safeguarding concerns, nurses and other health professionals have specific responsibilities. Their role usually has several elements:

  1. 1.

    Ensuring that patients are safe and that their immediate and future care needs are being met

  2. 2.

    Recognising the signs of abuse through assessment and preserving any evidence

  3. 3.

    Respecting the person’s views and wishes relating to the situation and those involved

  4. 4.

    Reporting suspected abuse through referral to appropriate professionals and agencies.

Holistic and thorough assessment as part of the comprehensive geriatric assessment (CGA) process (Chap. 6) is central to recognising risk or signs of abuse. Where there are concerns practitioners have a duty to share information [21].

Older adults sometimes have complex interpersonal relationships and may be ambivalent, unclear, or unrealistic in their views of their personal circumstances. They may be aware of their own vulnerability but also recognise their right to autonomy. Their right to make their own decisions takes precedence, therefore, over the duties of protection perceived by a practitioner [22].

Acting on concerns about elder abuse is complex. Policy and guidance vary around the world depending on local laws, guidelines, and culture. What is important is that practitioners are well educated about the guidance, able to take appropriate action, and communicate with appropriate agencies to ensure the safety of older people.

17.8 Decision-Making, Capacity, and Consent

Decision-making becomes more complex for those with multiple health and care needs as the capacity to self-manage is affected by the cumulative effects of these needs, sometimes leading to decisions being made on their behalf. However, healthcare providers must actively involve individuals in decision-making processes about their care. People vary in their degree of involvement as they take on various roles in the decision-making process. Some prefer to make their own decisions, some prefer others to make decisions for them, and some want to share the responsibility with others (e.g. the care provider). Older people emphasise the importance of participation and involvement in decisions about their care, highlighting negative consequences of the current emphasis on autonomy, personal choice, and freedom in both healthcare ethics and policy development.

The skills for sharing and discussing decisions with vulnerable patients, and their families, can be challenging to embed in services so there is a need to establish mechanisms that preserve and foster shared decision-making between professionals, patients, and carers and how they achieve improvements in patient outcomes.

17.8.1 Decision-Making Capacity

Decision-making capacity is a clinical assessment of a person’s ability to make specific healthcare decisions, whereas competency is a legal determination of the patient’s ability to make his or her own decisions in general. Decision-making is an important aspect of dignity.

The ethical principle of autonomy supports the right of patients with the decision-making capacity to determine their plan of care. Autonomy is a fundamental ethical principle in healthcare and includes respect for person and a person’s ability to make decisions relating to their wishes.

Adults are presumed to have decision-making capacity but may lack the ability to do so temporarily or permanently due to acute or chronic illness or injury. Assessment of capacity is critical to understanding whether and to what extent the patient can participate in clinical decision-making. The concept of decision-making capacity is complex and multidimensional, and there are no gold-standard instruments assuring its valid measurement.

A person with decision-making capacity is able to:

  • Understand the relevant information presented about the diagnosis, prognosis, treatment options, risks, and benefits of each option and alternative

  • Appreciate the consequences of the choice

  • Reason about the options in the context of personal values

  • Make and communicate a choice.

Informed consent is a legal process, grounded in the principle of autonomy, which ensures patients are adequately informed to make healthcare choices and give authorisation for procedures and other interventions. Informed consent is more than a document indicating the patient’s authorisation. The main elements of informed consent are:

  • Disclosure—the person must be given adequate information regarding the nature and purpose of proposed treatments, as well as the risks, benefits, and alternatives to the proposed therapy, including no treatment

  • Decision-making capacity—that the individual has capacity to make the specific decision

  • Voluntariness—the decision is being made without pressure or duress and free from coercion.

17.9 End-of-Life Decisions

For some patients, their fragility fracture, especially a hip fracture, may be an event that will hasten the end of their life—and it may occur because they are frail and already approaching the end of their life. Death, dying, and end-of-life are profoundly personal issues embedded within societal and cultural contexts. Understanding of the importance of individual preferences at the end of life is constantly shifting. In some communities, this is a facet of human existence that is increasingly seen as essential to facilitating a dignified death [23], while in others it is a private and personal topic that is rarely discussed openly. For those who live within cultures where death and dying are part of healthcare conversations, there are three main principles that relate to end-of-life situations and decisions following significant fragility fracture and surgery:

  1. 1.

    Do not attempt resuscitation decisions

  2. 2.

    Palliative care

  3. 3.

    End-of-life care

17.9.1 Do Not Attempt Resuscitation Decisions

Fractures and subsequent orthopaedic surgery can lead to significant deterioration in a patient’s health which can lead to cardiac arrest. Cardiopulmonary resuscitation is an invasive procedure that in some cases can lead to restoration of circulation and breathing. In most cases, however, resuscitation is unsuccessful, especially in patients who have multiple health conditions and/or are frail. This procedure was never meant to be applied to people who are suffering from irreversible conditions from which they are likely to die.

In many countries, “Do Not Attempt Resuscitation” (DNAR) decisions are recorded and applied when a person does not wish to be resuscitated or when resuscitation attempts are likely to be futile. Such decisions can be made and recorded by individuals in advance or made by clinicians at the time of cardiac arrest, but these decisions are a source of ethical concerns [24]. This may be a process that is, in fact, not openly discussed or considered, even in healthcare settings, in some countries or communities.

Most people who have suffered a serious fragility fracture will never have actively thought about what their wishes might be in this situation, so it is important that practitioners discuss this with patients and/or their loved ones whenever possible and in a way that respects their values.

Many countries have policies and guidelines in place which govern DNAR decisions, aiming to protect individuals from poor care, inconsistency in decision-making, communication, and documentation. Around the world, there are examples of significant progress in the development of clinical practice in this area. In some countries, there are formalised processes for emergency care and treatment planning (ECTP) which facilitate patient-centred discussions about CPR decisions [25]. In the UK, for example, the “Recommended Summary Plan for Emergency Care and Treatment” (ReSPECT) is supported by a document that prompts the inclusion of patients’ preferences in conversations and is held by the patient. These conversations support patients and clinicians to develop shared understandings of the patient’s condition and preferences, agree on a direction of care, and make shared recommendations about treatment options, including CPR [26].

17.9.2 Palliative Care

While surgery for major fragility fractures such as hip fractures is recommended for most patients; a few, especially those who are already frail, are unlikely to survive the physiological stress of the fracture and subsequent surgery. In this situation, the clinical team, led by the surgeon, may decide that surgery should not be conducted. Other patients may suffer significant and unresolvable health deterioration following surgery. In these situations, the principles of palliative care should be applied.

The World Health Organization [27] defines palliative care as:

“An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual”.

The fundamental aims of palliative care include [27]:

  • Provide adequate pain relief and minimise discomfort by providing symptom relief

  • Affirm life and regarding dying as a normal process

  • Intend neither to hasten nor postpone death but to

  • Integrate the psychological and spiritual aspects of patient care

  • Offer a support system to help patients live as actively as possible until death

  • Offer to provide a system of support to help the family cope during the patient’s illness and death and in their own bereavement

  • Work collaboratively as a team to address the needs of patients and their families, including bereavement counselling, if indicated

  • Enhance quality of life and positively influence the course of illness

  • Effectively and comprehensively manage distressing physical symptom and psycho-social problems pay attention to spiritual needs. Clinical and psychological complications at a location that meets the needs and wishes of the patient and family.

Surgery for hip fracture is still the most effective way to manage pain for patients who are reaching the end of life, so the reasons for the decision not to perform surgery must be clearly explained to the patient and/or family and ethical decision-making employed.

Palliative care is not limited by time and care should be delivered based on needs as they arise. It can take place in primary care, in acute hospitals and in long-term and hospice care facilities. Many patients who survive a hip fracture do not regain their pre-fracture functional level, and almost one third lose their independence [28]. Practitioners must be equipped for, and expect to deliver, end of life and palliative care in the orthopaedic and ortho-geriatric setting routinely rather than as an exception.

17.9.3 End of Life

End-of-life care focuses on a short period of time before death and includes a discussion of medical practices and decision-making. More people are living longer with more comorbidities and, unfortunately, the insult of a major fracture such as a hip fracture can see the patient’s health decline and ultimately result in end of life. It is estimated that there were approximately 54.6 million deaths worldwide in 2011 and that 9% of those were due to injuries [29]. Men have a higher risk of mortality after a hip fracture, but women are also at substantial risk of death; this risk exceeds the lifetime risk of death from breast cancer, uterine cancer, and ovarian cancer combined.

When considering the philosophy of “end of life care” [30], Dame Cicely Saunders said:

“You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die”.

Her words reflect the human responsibility to care for others in a humanistic and compassionate way until the end of their life.

There are many responsibilities in end-of-life care, ranging from communicating with individuals and families about their care and preferences; to observing, discussing, and recording any changes in condition and offering compassion and support. A broad range of care skills are needed along with awareness of the values which underpin this philosophy of care. When providing end-of-life care, practitioners should [31]:

  • Treat people compassionately

  • Listen to people

  • Communicate clearly and sensitively

  • Identify and meet the communication needs of each individual

  • Acknowledge pain and distress and take action

  • Recognise when someone may be entering the last few days and hours of life

  • Involve people in decisions about their care and respect their wishes

  • Keep the person who is reaching the end of their life and those important to them up to date with any changes in condition

  • Document a summary of conversations and decisions

  • Seek further advice if needed

  • Look after yourself and your colleagues and seek support if you need.

End-of-life care can be provided in a range of settings including the community, care homes, and hospices. Practitioners need to be attuned to noticing when a person is nearing the end of life or actively dying. How the patient and family communicate with/during this phase of life will depend on the individual patient. As much as possible, this should be patient-led and the nurse should proceed with gentle, honest answers, using a language the person understands. If the patient is uncomfortable or does not wish to talk about their dying or death, it is important to respect their wishes. It is crucial, however, to have sensitive conversations with families and carers to prepare them for impending death.

Good nursing care for those at the end of their life should include physical, emotional, and psychological aspects of care along with spiritual support. The process of dying creates multiple emotions and feelings for all involved: the patient, family, carers, and the care providers. It can be very stressful and complex. It is helpful to use tools to assist in identifying indicators that someone is approaching their end of life such as the Gold Standards Framework (GSF) [32] and the Palliative Performance Scale 2 (PPS). Nurses play a key role in helping the patient throughout this natural process. The gentle “winding down” at the very end of life can be very peaceful as the body starts to let go, so if the patient is distressed or restless, this can be disrupted.

Summary of Main Points for Learning

  • Vulnerability is a multidimensional construct, in which behavioural, socio-cultural, economic, and political conditions interact with biological processes throughout life.

  • Safeguarding involves protecting an adult’s right to live in safety, free from abuse and neglect.

  • Nurses’ assessment should be holistic and thorough considering the patient’s emotional, social, spiritual, psychological, and physical presentation as well as the identified older adult clinical needs. One of the most important points that need to be observed in taking care of the elderly is maintaining their dignity.

  • Decision-making becomes more complex for older people with multiple health and care needs as the capacity to self-manage is affected by the cumulative effects of long-term conditions.

  • The goal of end-of-life care is to prevent or alleviate suffering as much as possible while respecting the wishes of dying patients.

  • Fragility fracture, particularly hip fracture, may be a signal of, or hasten, the end of life. Palliative and end-of-life care is, therefore, an important aspect of the care process in both hospital and community settings. Physical, psychological, emotional, and spiritual care need to be provided in a sensitive and compassionate manner.

17.10 Suggested Further Study

Select some of the following sources of information to help you further explore your own thoughts about the topics discussed in this chapter:

  • Boltz M, Capezuti E, Zwicker D, Fulmer TT (eds) (2020) Evidence-based geriatric nursing protocols for best practice. Springer

  • https://nicheprogram.org/

    Nurses Improving Care for Healthsystem Elders (NICHE) imparts principles and tools to stimulate changes in clinical practice to achieve patient-centred nursing care for older adults in healthcare facilities. The vision of NICHE is that all older adults, age 65 and over, receive age-friendly, exemplary nursing care.

  • McSherry W, Rykkje L, Thornton S (eds) (2021) Understanding ageing for nurses and therapists. Springer, Cham, Switzerland

  • https://www.who.int/health-topics/ageing

  • Marks J, Predescu I, Dunn LB (2021) Ethical issues in caring for older adults. Focus (American Psychiatric Publishing) 19(3):325–329. https://doi.org/10.1176/appi.focus.20210011

Find local and national guidance for consent and capacity, safeguarding, palliative and end-of-life care, and use these to identify ways in which care might be improved with respect to these aspects of care.

17.11 How to Self-Assess Learning

  • Think about how you currently identify vulnerability of patients in your care?

  • Talk with your colleagues about how you currently maintain older adults’ dignity and personal values and identify an area in which you would like to make improvements. Write an action plan for this improvement, involving the whole team.

  • Using the case study in this chapter, or an example of your own, consider what skills do you/your team need to identify and act on patient abuse and neglect and how could you improve these skills?

  • Identify a person you have recently provided care for who was approaching the end of their life. Write a reflective account of the care you gave and analyse whether you feel it could have been improved.