Meeting ethical and nutritional challenges in elder care : the life world and system world of staff and high level decision-makers

Abstract

The overall aim of the thesis was to describe the issue of malnutrition and use it as a focal point of interest in elder care. A further aim was to illuminate how this issue could be addressed focusing on older adults' integrity and high level decision-makers' reasoning about ethically difficult situations (I-IV). Older adults, caregivers and high level decision-makers (HDMs) i.e. elected politicians and civil servants participated in the studies.

Study I focused on the frequency of underweight, weight loss and related risk factors among older adults living in 24 sheltered housing units located in one county. Measurements were obtained from 719 and were repeated after one year with the 503 still participating (I). Weight changes in older adults and changes in mealtime routines and environment were followed after a three month integrity promoting intervention. The participants were living at two nursing homes, 18 from the intervention ward (I-ward) and 15 from the control ward (Cward) (II). The HDMs` views and reasoning regarding malnutrition in elder care were illuminated (III). Also highlighted were the HDMs' experiences of the meaning of being in ethically difficult situations related to elder care (IV). Participating in studies 111-IV were eighteen HDMs from the municipality or county council level. The inclusion area encompassed two counties (IIV). Methods used in the studies were: descriptive statistics and logistic regression (I), descriptive and comparative statistics as well as manifest content analysis (II), latent content analysis (III) and phenomenological hermeneutic analysis (IV).

A considerable percentage of the older adults in the sheltered housing units were underweight or exhibited weight loss. After a year, significant changes were found such as declined cognitive and functional capacity, eating dependencies, and chewing and swallowing problems. Risk factors associated with underweight and weight loss were cognitive and functional decline, eating dependencies and constipation (I). After the intervention that included staff training, the meal environment and routines were changed and weight increases were seen in 13 of 18 older adults from the I-ward compared with two of 15 from the C-ward. The individual weight changes correlated significantly to changes in the intellectual functions. Increased contact with the older adults and a more pleasant atmosphere was reported (II). The HDMs cited the older adults' poor health status, caregivers' lack of knowledge and inflexible routines as possible causes for the malnutrition. They suggested the need for increased physician intervention, more education and individualised care. The HDMs placed the responsibility for the issues more with caregivers and physicians then with the local managements and themselves (III).

Both ethical dilemmas and the meaning of being in ethically difficult situations related to elder care were revealed by the HDMs (IV). The dilemmas mostly concerned difficulties of dealing with extensive care needs with a limited budget. Other aspects included the lack of good care for the most vulnerable, weaknesses in medical support, dissimilar focuses between caring systems and justness in the distribution of care. Being in ethically difficult situations was associated with being exposed, having to be strategic, feelings of aloneness, loneliness and uncertainty, lack of confirmation, risk of being threatened or becoming a scapegoat and avoidance of difficult decisions (IV).

Different levels in a health care system seem to be intertwined with ethical and nutritional challenges that confront and are associated with the different assumed roles. The results are reflected in the so called life world that concerns relationships, the system world that concerns routines and the governing of goals, and the tension between these two worlds. Structures that enable dialogues where ethical issues can be brought up from the different levels and between the different professionals inside the health care system seem to be important for the reduction of feelings of distrust and an improvement in elder care.