Evaporation of Elderly Nursing:Avoiding Ethical Scales to Weigh the Right to Dispose of Life
The provision of nursing care for older individuals in the United Kingdom (UK) is influenced by societal development and an increasing emphasis on social welfare, resulting in a broad range of theoretical frameworks. Due to the long lasting discussions on legal policies with the elderly, it is ‘not until the 20th century that medical and social care of the elderly received attention’, and the ‘swelling numbers’ of them make it an urgent issue from the legal aspects.[1] While the government has been trying to establish a stable structure of social welfare to maintain the nursing care system, COVID-19 disrupted this equilibrium, exposing potential risks and sparking conflicts between healthcare workers and the elderly. This article aims to examine the ethical dilemma concerning elder care and healthcare worker safety, commencing with an exploration of the healthcare system's disarray during the epidemic. It will also identify potential causes and propose solutions.
Photo credit: Unsplash
Systemic Disorder: Reality in Nursing Homes during COVID-19
Nursing homes worldwide have been severely impacted by the COVID-19 pandemic, with older individuals often bearing the brunt of the devastating consequences. This is evident in the case of care homes in the UK. For instance, in 2020, an independent investigation was initiated into the care home responsible for the majority of COVID-19 deaths on the Isle of Man. Out of the 24 individuals who succumbed to the virus on the island, 20 were residents of Abbotswood Nursing Home.[2] Similarly, the care home in Portree experienced a COVID outbreak in 2020, resulting in the death of ten residents.[3] These two cases unfolds the serious consequences and the uncontrollable situation led by COVID-19, which shows their exposure to death. Starving is also torture to most of the older people in nursing homes due to restrictions imposed during the pandemic, and many older people in nursing homes faced the distressing experience of malnutrition as their relatives were unable to assist with feeding.
While the vulnerability of older individuals may partly contribute to these fatalities, it is evident that systemic dysfunction within nursing homes played a significant role. Alastair Gray, representing Central Scotland Care Homes, highlighted that the issued guidance frequently changed, often with conflicting messages. Unrealistic expectations regarding the pace of implementation and the rapidly evolving nature of advice also raised concerns among staff, who feared they had been following incorrect guidance. [4] That is the systemic disorder which we need to discuss during Covid-19, a collapse of quantity of nursing workers and the uncertain of the issued guidance. And these examples also above suggest in a sideways way that the systemic disorder in nursing homes is a concomitant catastrophe in the context of COVID-19, or maybe other possible disasters, stemming from inherent gaps in the system of care requirements.
(Photo Credit: Google, Coronavirus: Independent investigation into Manx nursing home hit by Covid-19- accessed on, https://www.bbc.co.uk/news/world-europe-isle-of-man-52684620)
Due Entitlement: Rights for Older Individuals
In the context of care standards in the UK, the establishment of non-mandatory care regulations has been driven by societal demands for logical and pragmatic improvements. The safeguarding of older individuals is typically demonstrated through provisions aimed at standardising nursing homes, encompassing aspects such as facilities, staff, and services, as well as through explicit written rules specifically tailored to the needs of older people.
National Minimum Standards: Care Homes for Older People
The National Minimum Standards for older people serve as a supplementary framework to complement the fundamental provisions outlined in legislation.[5] Although these standards are not legally binding, they are closely scrutinized and compared against the actual practices when assessing the eligibility for care home registration or the potential cancellation of an existing registration.[6] This practice indirectly signifies the protective measures in place for prospective residents.
One of the main principles throughout pertains to humanitarian concerns. If the elderly choose to live in the nursing home, they can use the standards listed to ‘make that judgement and communicate it to their relatives or representatives, the staff or inspectors’ for whether this care home is nice to live or not.[7] However, for individuals with disabilities such as aphasia and dementia, Part II of the document outlines a set of key standards. These standards serve as guidelines for managers and inspectors to assess the performance of the care home in relation to its governing philosophy. Standard 7 specifically focuses on the development of individualized care plans for each elderly people, ensuring that their healthcare, medication, privacy, dignity, and considerations related to death and dying are comprehensively addressed. Further guidelines pertaining to these aspects can be found in Standards 8 to 11.[8]
At a practical level, Part IV of the document outlines the mechanisms for lodging complaints and ensuring protection.[9] This section primarily addresses the complaints procedures within the care home, specifically concerning matters between the resident and the proprietor or manager. Residents are encouraged to submit their complaints directly to the National Care Standards Commission (NCSC). An example of this is demonstrated in Standard 16, which emphasizes the importance of a concise and efficient complaints procedure, as well as effective communication with the NCSC.[10] Standard 17 acknowledges the legal rights of older individuals, encompassing aspects such as civic and political processes.[11] However, it is crucial to recognize that many older people are reluctant to lodge complaints, whether due to the difficulty they face in doing so or out of fear of potential victimization.[12] Therefore, care workers and social workers must exhibit heightened sensitivity and flexibility to meet the unique needs of older individuals.
In essence, the minimum standards stipulate that older people should be safeguarded and afforded their rights, both mentally and practically, irrespective of their condition or societal changes. In an ideal scenario, their criteria for assessing the worth of a life sentence should be respected. However, a peculiar and precarious aspect is that all these compassionate endeavours are grounded in non-mandatory frameworks, lacking proper recourse procedures following violations. This situation poses ethical challenges for care workers.
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Ethical Challenges: Conflicts between Duty and Life
In normal circumstances, care workers typically adhere to their daily work routines as long as the social situation remains safe and stable. The establishment of essential standards for older people is based on the contractual agreement between individuals and the social responsibility of care providers. However, when confronted with disasters like the COVID-19 pandemic, which significantly involves the risk of exposure to others, it creates a profound ethical dilemma for care workers. The balance between their own lives and their professional duties becomes a critical consideration. Unfortunately, due to the limited research available on the experiences of social workers and care workers during the pandemic, we will initially focus on discussing the ethical challenges faced by nurses, whose roles bear similarities to those of care workers.
The case highlighted by Carla O'Neill and Catherine S. O'Neill serves as commentary on the ethical dilemmas faced by nurses and midwives throughout the pandemic, arising from the conflicting obligations of patient care and self-care.[13] Nurses often encounter two main dilemmas in such situations. The first stems from the reality that they may be the sole individuals responsible for making discretionary professional judgments. [14]This means they may find themselves uncertain about whether it is appropriate to provide support or make decisions regarding end-of-life care, balancing the considerations of dignity and comfort against the utilization of intensive medical interventions, all while considering the potential legal consequences.
However, during the pandemic, an original conflict for the second dilemma emerges between Provision 2 of the ANA Code of Ethics for Nurses, which emphasizes the nurse's primary commitment to the patient, and Provision 5, which highlights that nurses owe a duty to themselves equal to that of others. [15]Nurses find themselves grappling with the challenge of balancing these principles, as they must care for their patients while also considering their well-being and the safety of their family members. The ethical dilemmas faced by nurses and midwives are further exacerbated when they are confronted with inadequate supplies of equipment and personal protective equipment (PPE).[16]
Similar situations arise in nursing homes for older people, which can be even more challenging compared to hospital settings. Care workers and social workers in these contexts often lack a formal code of ethics due to the voluntary nature of their roles and the limited quantification of these professions. Consequently, it is almost like a balancing exercise between 2 vulnerable parties with right to safety, health, and life. Moreover, the availability of legal recourse to address potential conflicts is also hindered, further complicating the resolution of unnecessary legal disputes. Ironically, beneath the facade of tranquility, the elderly individuals become inadvertent victims of the disaster, facing adverse consequences in practical terms.
(Photo Credit: Thinkstock, CQC place Dean Wood Manor nursing home in Wigan in special measures- accessed on https://www.bbc.co.uk/news/uk-england-manchester-35550508)
Avoiding Dilemma: Plans from various aspects
The conflicts that arise between care workers and older individuals can be viewed as conflicts between compassionate decision-making and pressing needs. These conflicts are not inherently oppositional, as they reside on different planes and are not fundamentally contradictory to one another. The occurrence of such dilemmas is often triggered by unforeseen disasters and a lack of adequate emergency preparedness. By adopting this perspective, we can proactively implement changes and make necessary preparations in advance to mitigate the impacts of these dilemmas.
Communications: individuals, family and nursing homes
One of the prominent risks within the nursing system for older people lies in the lack of communication between individuals and their relationships. [17]As previously mentioned, some of the elderly, for instance, is unable to interact with his family members due to being isolated, which restricts his ability to express his thoughts and desires beyond the confines of the nursing home. Conversely, from a different perspective, the inadequate dissemination of information regarding Mr. McGrath's health condition in a timely manner resulted in a tragic outcome due to insufficient awareness. It is crucial to redesign the communication dynamics, both within and outside the nursing home, and integrate it into the assessment system promptly. This would ensure that communication status is given due consideration and aligned with the requirements of the nursing home environment.
Conclusion: Care Planning in advance:
A significant number of older individuals succumb to non-pandemic-related underlying conditions during the pandemic due to factors such as age and the absence of timely life-saving interventions, including cardiopulmonary resuscitation. Insufficient evidence regarding the origins of the pandemic and concerns about the potential consequences of treatment programs contribute to this unfortunate outcome. [18]As a result, older individuals experience these unfortunate deaths. Despite the possibility of not initially discovering effective methods to save lives during future COVID-19 pandemics, engaging in advance care planning through contractual agreements and accredited clinics proves to be a valuable approach. For instance, when utilizing medical interventions to ensure the well-being of older individuals, it is important to prioritize their voluntary participation and consider their preferences beforehand. This proactive measure can not only potentially save lives but also assist healthcare professionals in mitigating unnecessary legal liabilities.
With advancements in medical techniques and the social welfare system, there exist numerous methods to prevent such dilemmas. For example, safe and effective vaccinations can be offered by the government or social welfare organizations to make sure those who are out of the capacity to protect themselves to gain the basic precautionary and reduce the possible harm due to the uncontrollable systemic disorders. The tragedies witnessed during the COVID-19 pandemic serve as a profound lesson, emphasizing the importance of directing attention not only towards critically ill patients but also towards vulnerable individuals, particularly older people who find themselves on the precipice of disasters.
[1] Michael Denham, ‘A Brief History of the Care of the Elderly’ (British Geriatrics Society, 23 June 2016) < https://www.bgs.org.uk/resources/a-brief-history-of-the-care-of-the-elderly > accessed 23 June 2016
[2] Ellan Vannin, ‘Coronavirus: Independent investigation into Manx nursing home hit by Covid-19’(British Broadcasting Corporation, 15 May 2020)< https://www.bbc.co.uk/news/world-europe-isle-of-man-52684620 > accessed 15 May 2020
[3] Scotland, ‘Scottish Covid Inquiry: Care home residents 'left to starve'’(British Broadcasting Corporation, 25 October 2023)< https://www.bbc.co.uk/news/uk-scotland-67217363 > accessed 25 October 2023
[4] Scotland, ‘Scottish Covid Inquiry: Care home residents 'left to starve'’(British Broadcasting Corporation, 25 October 2023)< https://www.bbc.co.uk/news/uk-scotland-67217363 > accessed 25 October 2023
[5] National Minimum Standards for Care Homes for Older People 2003, vii
[6] National Minimum Standards for Care Homes for Older People 2003, vii, viii
[7] National Minimum Standards for Care Homes for Older People 2003, 7
[8] National Minimum Standards for Care Homes for Older People 2003, 7-12
[9] National Minimum Standards for Care Homes for Older People 2003, 17
[10] National Minimum Standards for Care Homes for Older People 2003, 17-18
[11] National Minimum Standards for Care Homes for Older People 2003, 18
[12] National Minimum Standards for Care Homes for Older People 2003, 17
[13] Georgina Morley, Christine Grady, Joan McCarthy, Connie M Ulrich, ‘Covid-19: Ethical Challenges for Nurses’ (2020) 35
[14] Georgina Morley, Christine Grady, Joan McCarthy, Connie M Ulrich, ‘Covid-19: Ethical Challenges for Nurses’ (2020) 36
[15] ANA Code of Ethics for Nurses
[16] Georgina Morley, Christine Grady, Joan McCarthy, Connie M Ulrich, ‘Covid-19: Ethical Challenges for Nurses’ (2020) 38
[17] O'Keeffe, Shaun, ‘COVID-19 Pandemic and Decision-Making about Cardiopulmonary Resuscitation and Advance Care Planning’ (2021)
[18] O'Keeffe, Shaun, ‘COVID-19 Pandemic and Decision-Making about Cardiopulmonary Resuscitation and Advance Care Planning’ (2021)
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