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Too complex and time-consuming to fit in! Physicians' experiences of elderly patients and their participation in medical decision making: a grounded theory study
Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Geriatric Medicine in Norrköping.
Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Department of Geriatric Medicine in Norrköping.
Linköping University, Department of Social and Welfare Studies, NISAL - National Institute for the Study of Ageing and Later Life. Linköping University, Faculty of Arts and Sciences.ORCID iD: 0000-0003-2191-4728
Linköping University, Department of Social and Welfare Studies, Division of Health, Activity and Care. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in East Östergötland, Center of Palliative Care.ORCID iD: 0000-0002-9606-3238
2012 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 2, no 3Article in journal (Refereed) Published
Abstract [en]

Objective To explore physicians' thoughts and considerations of participation in medical decision making by hospitalised elderly patients.

Design A qualitative study using focus group interviews with physicians interpreted with grounded theory and completed with a questionnaire.

Setting and participants The setting was three different hospitals in two counties in Sweden. Five focus groups were conducted with physicians (n=30) in medical departments, with experience of care of elderly patients.

Results Physicians expressed frustration at not being able to give good care to elderly patients with multimorbidity, including letting them participate in medical decision making. Two main categories were found: ‘being challenged’ by this patient group and  ‘being a small part of the healthcare production machine’. Both categories were explained by the core category ‘lacking in time’. The reasons for the feeling of ‘being challenged’ were explained by the subcategories ‘having a feeling of incompetence’, ‘having to take relatives into consideration’ and ‘having to take cognitive decline into account’. The reasons for the feeling of ‘being a small part of the healthcare production machine’ were explained by the subcategories ‘at the mercy of routines' and ‘inadequate remuneration system’, both of which do not favour elderly patients with multimorbidity.

Conclusions Physicians find that elderly patients with multimorbidity lead to frustration by giving them a feeling of professional inadequacy, as they are unable to prioritise this common and rapidly growing patient group and enable them to participate in medical decision making. The reason for this feeling is explained by lack of time, competence, holistic view, appropriate routines and proper remuneration systems for treating these patients.

Place, publisher, year, edition, pages
B M J Group , 2012. Vol. 2, no 3
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-80824DOI: 10.1136/bmjopen-2012-001063ISI: 000315044800075OAI: oai:DiVA.org:liu-80824DiVA: diva2:548451
Available from: 2013-03-28 Created: 2012-08-30 Last updated: 2017-12-07Bibliographically approved
In thesis
1. Frail and Elderly Hospital Patients: The Challenge of Participation in Medical Decision Making
Open this publication in new window or tab >>Frail and Elderly Hospital Patients: The Challenge of Participation in Medical Decision Making
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: In research, patient participation in medical decision-making has been shown to be associated with higher patient satisfaction and improvement of treatment outcomes. But when it comes to patient participation when being old and frail there are pitfalls and the research in this area is sparse.

The aim of this thesis is to explore participation in medical decision making of the frail elderly patient in hospital from the perspectives of patients themselves and the health care staff. In this thesis frail, elderly patients is defined as individuals 75 years old or older, who during the past 12 months have received inpatient hospital care three or more times and who have three or more diagnoses in three or more diagnostic groups according to the classification system ICD-10.

The participants were frail patients’ in hospital or newly discharged and it was health care personnel working with frail elderly patients. In three of the studies the method was mainly qualitative (Paper I, III, IV) and in one (Paper II) quantitative. The qualitative methods were one-to-one tape-recorded interviews of 25 patients (Paper I and IV), 18 personnel (III and IV), 5 focus group interviews of physicians (Paper III) and 26 days of observations in hospital wards (IV). Chosen methodologies of analysis were content analysis and Grounded Theory. The quantitative study (II) was a cross-sectional survey using telephone interviews with patients (n= 156). This material was descriptively analysed and examined using weighted kappa statistics.

Results: The results reported in Paper II show that elderly patients generally want to participate more in medical decision making than they do, though preferences for degree of participation are highly individualized – both findings important to consider in clinical practice.

According to the patients important key concepts of patient participation in medical decision making are to be listened to and to be informed (Paper I). The main reasons for not being able to participate included having many illnesses and generally, overall bad medical condition (Paper II). Also, cited as a problem was difficulty in understanding medical information, for example when given by a foreign-speaking physician (Paper I, II and IV). Frail, elderly patients complained that they were less informed than was their preference (Paper I, II and IV).

Moderate agreement was obtained between patient’s preferred and actual roles in medical decision making. Patients often expressed gratitude and confidence in their health care (Paper I and IV), but also, sympathy for stressed health care personnel who had so much to do.

The frail elderly patients do sometimes feel like a burden to the health care (Paper I and IV). The professionals gave expressions of trying to avoid taking care of frail elderly patients and at the same time expressions of frustration and bad conscience not being able to take good care of them due to lack of time and lack of beds (Paper III, IV). Especially the physicians felt they were trapped between the needs of the patients’ and the remunerations system rewarding time-constricted health care production (number of investigations, operations, easy accessibility) – not a time-consuming holistic view on all illnesses and medications including communication with the patients and all caregivers involved (Paper III).

Both patients and the professionals perceive the hospital as some kind of “institution of power”, difficult to challenge, and the decisions of which one has to accept.

Conclusion: In this thesis there are shown a number of challenges to participation in medical decision making by frail, elderly patients, which thus limits quality of care for this patient group. Health care is revealed as not well adapted to meet these patients’ complex needs. A model is presented that explains how the organisation of health care, and the reimbursement system, does not facilitate a holistic view. The health care professionals appear to adapt to the organisation and the remuneration system, which leads to practices, such as, rapid discharges and a tendency to examine the patient for only one or a few problems. Finally a suggestion for a model to improve care of frail elderly patients is presented. This model includes the need of more hospital wards being able to work with a holistic view, better skills in gerontology and geriatrics and a more adapted remuneration system for the frail, elderly patients.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2012. 84 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1297
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-81408 (URN)978-91-7519-947-4 (ISBN)
Public defence
2012-10-05, K1, Kåkenhus, Campus Norrköping, Linköpings universitet, Norrköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2012-09-13 Created: 2012-09-13 Last updated: 2017-07-07Bibliographically approved

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Wissendorff Ekdahl, AnneHellström, IngridAndersson, LarsFriedrichsen, Maria
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