GEMSEM Gold 2022 - Welcome
6 May 2022
When you’re at a dinner party and mention that you work in an emergency department, your friends probably imagine you treating young or middle-aged people who have had car accidents, overdoses or heart attacks, all day. Because that’s what emergency medicine looks like on television.
But insiders, like us, know that the real work done in EDs is not so dramatic. It’s not so black and white. It tends to present across the full spectrum of grey.
Some of the most rewarding moments of my career have involved caring for elderly people in emergency departments. The proportion of patients aged over 65 has increased markedly since I commenced practice just over 20 years ago, and I feel highly privileged to have been trusted with their care. I have made satisfying diagnoses and engaged in fascinating conversations. In the process, I have also had all my biases and assumptions turned inside out and upside down.
White, western culture is obsessed with youth. Many of us, who grow up immersed in this culture, are scared of getting old. We don’t talk about death and dying. We feel uncomfortable about ageing, so we resort to platitudes and stereotypes. We are too quick to project our own beliefs onto the people who seek our care.
Emergency clinicians have a strong sense of social justice. We see the socioeconomic determinants of health inequity up close. We are proud to provide care for vulnerable populations. Yet somehow, when it comes to one of the largest groups who seek emergency care, we fail to see how our biases might contribute to their marginalisation.
The methods we use to weigh up the cost effectiveness of clinical interventions, using QALYs (quality adjusted life years) and DALYs (disability adjusted life years), are highly skewed against the elderly. There is a deficit of evidence regarding the efficacy of many common medications and procedures in older patients. Qualitative research about the expectations and experiences of elderly people when they interact with aged care and health services is a relatively new phenomenon, and, until recently, older people have lacked a coordinated consumer voice.
Clinicians miss important things in older patients when we fail to consider complexity that we actively seek in other patient groups. Addiction, mental health problems, abuse and neglect, social isolation, malnutrition, climate stress, housing instability and poverty – are all, unfortunately, relatively common, among elderly patients we meet in ED. Their presence compounds and exacerbates other medical and social problems.
There are four prima facie principles of medical ethics – beneficence (do good), non-maleficence (do no harm), respect for autonomy, and justice.
Each of these principles is important. I think we need to remember them, and strive even harder to observe them, when we care for older people in emergency departments.
Above all, we need to treat the person in front of us, in accord with their values and beliefs, not our own assumptions. We must aim to do this with the same standard of evidence and training that we expect when treating other patient groups.
Looking after elderly patients in ED is a great honour, and a great responsibility.
I look forward to the conference today, and I would like to thank Dr Nemat Alsaba and the organising team for creating such an engaging, multidisciplinary program. Coming together like this, to learn from each other and share ideas, is an important step towards providing more effective, person-centred, collaborative emergency care.
