The Unique Legal Risks of Treating Geriatric Patients
If the end of an ED patient’s life is in view, some EPs might see it as futile to expend a lot of time and energy to prolong that life, according to John C. West, JD, MHA, DFASHRM, CPHRM.
“There can be an inherent bias against older adults. ED physicians may ‘write them off’ and not take them seriously because they are old,” says West, principal at West Consulting Services, a Signal Mountain, TN-based risk management and patient safety consulting firm.
Geriatric patients are subject to “vulnerable adult” laws that vary by state. “ED physicians absolutely have an obligation to report elder abuse if they become aware of it,” West says. “There is little downside risk to reporting abuse. The reporter gets qualified immunity if the report is made in good faith.”
Older adults undergo more diagnostic tests, stay longer in the ED, and are more likely to be admitted to the hospital vs. younger patients, says Marie Boltz, PhD, GNP-BC, FGSA, FAAN, professor at the Penn State Ross and Carol Nese College of Nursing.
“ED providers are challenged to do a comprehensive evaluation to detect critical health issues hidden within a complex clinical and social presentation,” Boltz says.
Older adults may present to the ED with vague complaints that in fact indicate serious disease. One 88-year-old woman reported mild lower abdominal pain that she described as “not too bad.” The patient’s daughter was worried because the pain had persisted for three days. The patient’s vital signs were normal, with slight hypothermia and no leukocytosis.
Upon exam, there was mild tenderness in the right lower quadrant, no rebound tenderness, and no guarding. The eventual diagnosis was appendicitis with an atypical presentation. “Younger patients typically have fever, leukocytosis, nausea, vomiting, pain localized to the right lower quadrant, with guarding and rebound tenderness,” Boltz notes.
When compared to younger persons, older adults are more likely to experience missed or incorrect diagnoses and inadequate pain management.1,2 “Older adults who are discharged from the ED are more likely to be readmitted. They also risk functional loss and higher rates of mortality,” Boltz says.
Whenever possible, and with the permission of the older adult, the ED nurse should include the patient’s significant other, family, or support person in the assessment process. That person might convey something that changes the diagnostic picture (e.g., the patient fell recently, or the patient recently exhibited an abrupt change in mental status). “Risk assessment is necessary to prevent avoidable functional decline, falls, medication errors, and delirium,” Boltz says.
In Boltz’s experience, two tools are particularly helpful: The Identification of Seniors at Risk instrument and the Triage Risk Screening Tool. These evaluate the presence or absence of risk factors for adverse outcomes.
“These tools are useful in guiding a plan to prevent avoidable complications during the ED stay, if admitted during hospitalization, and after an ED visit when discharged,” Boltz says.
For ED nurses, Boltz says the main challenge is to identify high-risk patients more likely to benefit from a comprehensive geriatric evaluation and follow-up, a longer observation time (or access to observation units), and appropriate referrals (primary physician, geriatric evaluation and management unit, and/or social service).
Prevent delirium by controlling noise and avoiding bright lights. “Cohort older adults, when possible, after triage, in a space away from trauma or high-traffic areas,” Boltz says.
To assess for fall risk, nurses can use a tool such as the Timed Up and Go test. “Pay attention to toileting,” Boltz says. “For the person who is at risk for injury caused by cognitive impairment, weakness, and low mobility, provide low beds with bedside mats.” Finally, nurses should conduct a thorough medication reconciliation to look for polypharmacy and inappropriate medications. For instance, commonly used over-the-counter medications contain diphenhydramine. “In older adults, it often causes confusion, dizziness, falls, and urinary retention,” Boltz cautions.
- Hwang U, Richardson LD, Harris B, Morrison RS. The quality of emergency department pain care for older adult patients. J Am Geriatr Soc 2010;58:2122-2128.
- Hwang U, Shah MN, Han JH, et al. Transforming emergency care for older adults. Health Aff (Millwood) 2013;32:2116-2121.
When compared to younger persons, older adults are more likely to experience missed or incorrect diagnoses and inadequate pain management. Older adults who are discharged from the ED are more likely to be readmitted. They also risk functional loss and higher rates of mortality. Whenever possible, and with the permission of the older adult, the ED nurse should include the patient’s significant other, family, or support person in the assessment process.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.