Department of Geriatric Medicine, Western Health, Melbourne, Victoria, Australia.
Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
Intern Med J. 2022 Aug;52(8):1304-1312. doi: 10.1111/imj.15862. Epub 2022 Jul 23.
Older people living in squalor present healthcare providers with a set of complex issues because squalor occurs alongside a variety of medical and psychiatric conditions, and older people living in squalor frequently decline intervention. To synthesise empirical evidence on squalor to inform ethical decision-making in the management of squalor using the bioethical framework of principlism. A systematic literature search was conducted using Medline, Embase, PsycINFO and CINAHL databases for empirical research on squalor in older people. Given the limited evidence base to date, an interpretive approach to synthesis was used. Sixty-seven articles that met the inclusion criteria were included in the review. Our synthesis of the research evidence indicates that: (i) older people living in squalor have a high prevalence of frontal executive dysfunction, medical comorbidities and premature deaths; (ii) interventions are complex and require interagency involvement, with further evaluations needed to determine the effectiveness and potential harm of interventions; and (iii) older people living in squalor utilise more medical and social resources, and may negatively impact others around them. These results suggest that autonomous decision-making capacity should be determined rather than assumed. The harm associated with squalid living for the older person, and for others around them, means a non-interventional approach is likely to contravene the principles of non-maleficence, beneficence and justice. Adequate assessment of decision-making capacity is of particular importance. To be ethical, any intervention undertaken must balance benefits, harms, resource utilisation and impact on others.
生活在肮脏环境中的老年人给医疗保健提供者带来了一系列复杂的问题，因为肮脏环境与各种医疗和精神疾病并存，而且生活在肮脏环境中的老年人经常拒绝干预。为了综合有关肮脏环境的经验证据，以便在管理肮脏环境时使用原则伦理框架为道德决策提供信息。使用 Medline、Embase、PsycINFO 和 CINAHL 数据库对老年人肮脏环境的经验研究进行了系统的文献搜索。鉴于迄今为止证据基础有限，因此采用了解释性综合方法。有 67 篇符合纳入标准的文章被纳入综述。我们对研究证据的综合表明：(i) 生活在肮脏环境中的老年人普遍存在额叶执行功能障碍、多种合并症和过早死亡；(ii) 干预措施复杂，需要机构间参与，需要进一步评估干预措施的有效性和潜在危害；(iii) 生活在肮脏环境中的老年人使用更多的医疗和社会资源，并且可能对周围的人产生负面影响。这些结果表明，应该确定自主决策能力，而不是假设。肮脏生活对老年人及其周围人的伤害意味着非干预方法可能违反不伤害、有益和公正的原则。充分评估决策能力尤为重要。为了合乎道德，任何干预措施都必须平衡收益、危害、资源利用和对他人的影响。
