Choosing the right care for people from nursing homes: Hobson’s Choice, Morton’s Fork or Buridan’s Ass?

Glenn Arendts is Associate Professor in Emergency Medicine at the University of Western Australia and Chair of the Geriatric Special Interest Group of the Australasian College for Emergency Medicine. He writes about his Age & Age paper. 

donkeyHobson’s Choice: A choice where there is really only one option
Morton’s fork: A choice between two equally unpleasant alternatives
Buridan’s Ass: A hungry donkey placed equal distance from two identical bales of hay cannot use reason to choose between them, and so dies of hunger

Take a straw poll of hospital emergency department (ED) staff and you will find majority support for the following statement: “too many people from nursing homes are sent to the ED”. That your poll results may say something about the views of some hospital staff toward nursing home (NH) residents is immaterial. Acute medical care of dependent people with life limiting illness is an area of legitimate concern, and the prevailing orthodoxy is that ED is a less than ideal place to deliver it. For decades, health services have invested in a variety of programs and interventions to reduce the transfer from NH to ED.

Ultimately, the success of any such program is dependent on how readily it meets the needs of residents and others involved in the transfer of residents from NH. Unless decision makers perceive that the service meets these needs, they will opt for transfer. Mostly, alternatives to transfer are currently configured through a two step process: look at why people are coming to ED from NHs, then design the service to provide that care in the NH instead. This process ignores the complexity of the decision to transfer, which often results in transfers that have nothing to do with the acute health issue of the resident.

In our recent paper published in Age and Ageing, we report the results from a study in which residents, their relatives and NH staff were asked to choose from care options for accessing acute medical care should the resident have chest pain, suspected pneumonia or a fractured wrist following a fall. The care options were described by characteristics that are consistently promoted as important quality of care measures. These included how quickly the care was provided, how much the care relieved suffering and the complication/failure rate.

The results were revealing. Even if alternative services provided identical features to ED care, there was a strong overall preference for the ED over alternatives. This preference held across each of the respondent groups but was scenario specific, being strongest for pneumonia and weak for wrist fracture. These results can be interpreted two ways: either there are aspect/s of ED care not captured by the characteristics we used to describe services; or the preference for ED is driven by things that cannot be captured experimentally, and is akin to a learnt response (chest pain=call an ambulance).

The implications of our research for policy makers are considerable. Most transfers to ED are for serious medical issues such as those in our study. If the aim of policy makers is to significantly impact on transfers by providing alternative services in facilities, care quality provided by these alternatives will have to exceed that of ED to “break even”. Perhaps it will ultimately prove more efficient to make our ED’s better places to care for older people from NH instead?

Read the Age & Ageing paper ‘Preferences for the emergency department or alternatives for older people in aged care: a discrete choice experiment’

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