The Hospital Care of People with Dementia
Time spent in hospital can be bad for patients living with dementia. What can be done about this?
The Ottoline Club met online on 19th November 2020 to hear a talk by Paula Boddington, of the Faculty of Philosophy at Northeastern University London, and Katie Featherstone, Reader in Healthcare Sciences at Cardiff University, on the hospital care of people living with dementia.
At a time of resurgent challenges to hospitals from Covid-19, it was salutary to be able to hear and talk about a longer-running and increasingly serious issue in clinical provision, the hospital care of people living with dementia. This is the focus of an interdisciplinary research team based at Cardiff University. Paula has participated in the work of this team, contributing her philosophical expertise to a range of specific projects. She co-spoke this evening with the team leader, Katie Featherstone, who’s Reader in the School of Healthcare Sciences at Cardiff. Their talk related particularly to a couple of articles they have recently published together, on ‘the presentation of the clothed self’ and on the use of signs and symbols to label patients on the wards.
The team’s research began in 2015, following classic ethnographic methods: in eight different hospitals, Katie and her collaborators have observed everyday care on the wards, shadowing nurses and health care assistants, talking to people living with dementia during their admission and through their hospital stay, and also talking to their families. The projects aim to increase awareness of patients’ experiences, and thereby to improve care, and so the team collaborates not only with clinical personnel but also with NHS management and with the Welsh government’s policy-makers.
Interest has been great, and unsurprisingly so, given the numbers: there are now almost twice as many people with some degree of dementia on the regular wards as there were a decade ago, with an occupancy of up to 50 per cent of beds. Such patients suffer much functional deterioration during their stays, and they are twice as likely to die as other patients with similar acute conditions.
This evening’s talk especially considered attributions of dementia to patients on the ward. What prompts feed into a nurse’s judgement of a particular patient’s mental condition, and what unlooked-for consequences can such judgements have? Katie and Paula outlined two areas of concern.
There is, first, the practice of stripping patients of personal accoutrements: clothes and other possessions are hidden away in the interests of tidiness and safety. This can affect the patient’s sense of self, especially since he or she is also ill with an acute condition. Distressed or disorientated responses are liable to be taken as indicative of mental deterioration and lead to restrictive measures which may themselves exacerbate the situation.
Besides these negatively biased feedback loops, Paula and Katie discussed, secondly, the effects of various symbols that are used as labels to signify to busy staff a patient with dementia. Partly for reasons of precaution, it’s very easy to interpret these symbols more rigidly in practice than the wide range of possible degrees of dementia warrants, with the risk again of exacerbating many patients’ condition.
The presence of the symbols also directs attention away from the possibilities of communication. Paula suggested that these findings have implications regarding social robotics, where there is likewise a risk of making assumptions that fail to see and value the complex human interactions involved in care work.
In the discussion, Brian ventured to classify the main problems revealed into three: institutional culture, technologies not fit for purpose, and individuals’ failings. Katie and Paula both responded that the last factor tends to be given too much prominence at the expense of the other two; frequently it’s thought that better training is all that’s called for. Under the heading of ‘ward culture’, Paula and Katie said the use of metrics such as the number of falls on a ward in a week was unhelpful, along with the strongly hierarchical structures.
Mark wondered whether recent trends in the philosophy of mind which widen the mental domain, seeing it as embedded not only in the whole body but in the wider environment, are helpful in thinking about dementia in the hospital. Paula in response observed how in patients social awareness can persist quite strikingly when much else is disrupted. Charlotte reflected on what a deep difference it makes when the depersonalisation that is a common experience for all sorts of people in hospital becomes in effect, for those with dementia, irreversible.
Gulzaar asked how fully it is understood quite why the proportion of hospital beds occupied by people with dementia has risen so sharply. Katie and Paula replied that while it is recognised that this is partly due to hospital care and social care often not being sufficiently well joined up, it is also to a very large extent the result of such patients’ condition deteriorating in hospital, not only because of infections and as an effect of other practices such as continence care, but very much for the reasons relating to recognition and categorisation outlined in the talk. These, they stressed, will not be easy to mitigate, given for instance how prevalent time-pressure is in hospital care. But they can be addressed, and the project is addressing them, both on the small scale in terms of initiatives in individual wards and at the policy level in consultation particularly with Public Health Wales.
Those attending were: Paula Boddington and Katie Featherstone, Charlotte Grant and Catherine Brown (Faculty of English), Michael Peplar (Faculty of History) and Brian Ball, Alexandros Koliousis, Gulzaar Barn, Dimitris Mylonas, Mark Windsor and David Mitchell (Faculty of Philosophy).
Katie Featherstone and Andy Northcott of the research team have a book just out, Wandering the Wards: An Ethnography of Hospital Care and its Consequences for People Living with Dementia. Click HERE to download the book free via Kindle