IM25.19-21 | Geriatric Social and Ethical Care — Summary & Reflection

KEY TAKEAWAYS

Geriatric social and ethical care addresses the non-biomedical dimensions of ageing that profoundly shape health outcomes and clinical decision-making.

Social problems of the elderly:
- Social isolation — reduced social contact and loneliness; associated with increased mortality, cognitive decline, depression; screen with UCLA Loneliness Scale or simple clinical questions
- Elder abuse — six forms (physical, psychological, financial, sexual, neglect, abandonment); financial abuse is the most prevalent in India; screen with EASI; respond with documentation, safety assessment, reporting (Maintenance Act tribunals, police), and referral (HelpAge India, ASHA)
- Changing family structure — nuclear family migration, erosion of joint family, economic dependence creating vulnerability

Social interventions:
- Domiciliary services — home health aides, domiciliary nursing, physiotherapy, meals delivery, telehealth, ASHA follow-up
- Day care and rehabilitation centres — structured programmes, physiotherapy, OT, social activities
- Old-age homes — free (destitute), subsidised (BPL), private; Maintenance Act 2007 mandates old-age homes in every district
- State programmes — IGNOAPS pension, PMVVY, NPOP; Maintenance Act 2007 tribunal for family maintenance obligations

Ethical issues:
- Four principles: autonomy, beneficence, non-maleficence, justice — all four apply in geriatric contexts with specific tensions
- Capacity — decision-specific, time-specific, presumed present; assessed with MacCAT-T framework
- Advance directives — legally valid in India (Common Cause 2018); registered with Collector; Medical Board for implementation
- Goals-of-care conversations — structured, using SPIKES protocol; autonomy of capacitous patients takes precedence
- Ageism — ethically impermissible; allocate resources on clinical need not age alone

REFLECT

Return to Gopal from the opening hook — bruised, malnourished, and reporting that family members take his pension. You now have the clinical, social, and ethical tools to respond. Think through: Which form of elder abuse is occurring? What capacity assessment would you perform before deciding on his discharge? If he has capacity and chooses to return home, what is your ethical obligation? What Indian legal provisions protect him, and how would you initiate them? Beyond Gopal, reflect on this: the medical curriculum teaches you to diagnose and treat diseases, but most of the factors that will determine an elderly patient's quality of life are social and ethical — family support, financial security, safety from abuse, and the right to make their own decisions. What changes would you advocate for in your future practice or institution to ensure elderly patients receive not just good medicine but good social and ethical care?