The fine line: helpful or harmful care for older people

Introduction

Families, friends and professional care services generally try to do the best they can to meet an older person’s needs in every possible way and enhance their quality of life. However, even with the best intentions, it’s possible to do harm instead.

How can helpful care be harmful? The fine line is whether the care provided is what the recipient wants. If, as carers, we assume we know what’s best for the older person, there’s a good chance our decisions won’t align with what they want and like.

In that case, we could inadvertently cause detrimental effects to the older person – anything from annoyance or discomfort to extreme duress. Instead of being helpful, our well-motivated actions could even constitute elder abuse.

Here are some examples of well-intentioned care having the opposite effect.

SG’s story: overprotective adult children

SG and her husband have four adult children. During the COVID-19 pandemic, all four contacted their parents multiple times every day to check on them, which SG found frustrating and constricting. When SG drove to a shop to collect an online order through the car window, it caused a ‘family explosion’ because she had left the house.

The children were spurred by media coverage of the very real risks that COVID-19 presented for older people, but their well-meaning actions caused her and her husband a great deal of stress on top of the trials and challenges of lockdowns.

Anne’s* story: a simple courtesy step

The carers at 79-year-old Anne’s residential home were dedicated to their clients. Yet whenever a carer entered Anne’s room, she would pointedly look away and not acknowledge them. The carers found it difficult to attend to her needs and became concerned about her welfare.

When one of the carers, Peter, finally managed to get Anne to talk to him, he learned that Anne simply disliked people entering her room without knocking – she found it incredibly rude. After this, Peter and the other carers made sure they always knocked before entering their clients’ rooms.

Anne felt respected and listened to and responded better to their visits. In turn, they were better able to look after her.

How can caregivers know whether what they’re doing is helpful, not harmful? Here are two key steps:

• treat the older person as an individual, so that care is ‘person-centred’

• understand the older person’s rights and respect them in the way we provide care.

Treat the older person as an individual

It can be easy for others to generalise about older people, especially those who are experiencing a degree of cognitive decline. Seeing older people as one homogenous group is ageism, and it can lead caregivers to act with a ‘one size fits all’ approach.

But older people are individuals with their own particular needs and preferences, no matter their age, their health or where they live. Each older person has their own background, experiences and history that inform their likes, dislikes, reactions and hopes.

Take a person-centred care approach

A ‘person-centred’ approach to care treats and respects each older person as an individual. This means finding out what is important to the person so the care provided can be aligned to those preferences. Caregivers simply need to consult the older person about what they prefer and listen to their answer.

Avoid generalising about a person’s behaviour

Carers may sometimes dismiss an older person’s behaviour as ‘challenging’ without considering that there may be all kinds of historical or psychosocial reasons behind it. For example, what might seem like an insignificant change to us, like moving into residential care or discovering a new person in their home care team, might be much more significant for the person experiencing the change.

Rather than dismissing the behaviour as ‘challenging’, we could consider the individual person’s past, preferences and values to understand what is really going on. This will enable us to tailor our care approach and meet their specific needs.

Rosie’s* story: the ‘demanding’ client

One residential care client, Rosie*, was described in her care plan as ‘difficult’ and ‘demanding’ because she refused the food she was offered and seemed to be making constant demands on the staff. This made it hard for Rosie to receive the care she needed. However, the real reason she refused to eat was that she was confused about time and place, while her efforts to communicate were ineffective because of mental health problems. Seeing Rosie’s behaviour as ‘difficult and demanding’ left her vulnerable.

Use care plans effectively

Professional services use care plans to record and guide an individual’s care provision. If the plan is accurate, comprehensive and updated as the person’s needs change, it has great potential to protect an older person’s rights and ensure they receive care the way they like.

However, if it isn’t, the care plan may end up could causing the older person harm and denying them their rights.

Alice’s* story: care plan leads to problems

Alice lost the use of her legs after a stroke and moved into residential care after six months of rehabilitation. The stroke didn’t affect her cognitive ability, but Alice wasn’t consulted during the completion of her care plan.

Alice became unwell twice after taking her medication, and after the second incident she asked to see her care plan. She found a mistake in the details of her medication schedule in the plan. Alice had the error corrected and hasn’t had any further trouble with her medication.

Understand and respect the older person’s rights

The rights that everyone enjoys throughout their lives don’t change or diminish as we get older or if our health declines. Looking at care provision from a rights perspective can make sure we don’t cause an older person harm or distress.

For instance, every older person still has the right to make their own decisions, even if we don’t agree with the way they make them. They have the right to choose what they have or do, who they wish to see, and what care they receive. So if we provide care the way we think it should be and don’t consult the older person about it, we deny them their rights.

If rights aren’t respected

What happens if we fail to respect an older person’s rights? The effect may be that we end up limiting their personal freedom, causing them discomfort or distress, or even committing elder abuse by overlooking their needs. The helpful care that’s meant to bring them comfort and pleasure could become harmful instead.

Robert’s* story: how often to shower

90-year-old Robert feels the cold, so he prefers to shower on alternate days during winter instead of every day. However, his new home care worker had been instructed that daily showering was important. On the first morning they met, Robert told his carer he wishes to shower Monday, Wednesday and Friday, and the carer replied that his adult children said he was to shower daily. Robert felt like he was being treated like a child and refused to shower every day.

The carer’s supervisor made a home visit and mediated between everyone involved. Robert’s family and his carer were able to understand that he had the right to decide the care he wanted. Everyone reached an agreement that he would shower on alternate days but change his clothes daily. Robert felt listened to and respected.

Respect the older person’s space and place

Older people are individuals with rights to respect and courtesy, and this extends to their home and private space. They have the right to have things set up the way they like. They may be deeply attached to their belongings or feel secure through knowing exactly where things are.

Well-intentioned tidying up of their home or room without their consent may be hurtful. It could cause confusion and even put them at risk of a trip or fall. As carers, we should ask before undertaking any rearranging or tidying up. If they agree, we should involve them in how it’s done and let them tell us what they want.

John’s* story: his newspapers and the tidy friend

John, 82, loved reading the newspapers, even past editions. He kept a pile on his bedside table at home, neatly stacked so they didn’t fall and trip him over or prevent him getting into bed.

One day his friend removed the newspapers without asking John. He thought he was helping by making the bedside table tidy and available for other items. Instead of feeling cared for, John felt ignored and angry. He also could no longer find the articles he wanted, so his reading enjoyment was disrupted and he gave it up.

*Names changed to protect privacy