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Thai family caregivers’ experiences helping dependent elders during medical emergencies: a qualitative study
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Research paper
Thai family caregivers’ experiences helping dependent elders during medical emergencies: a qualitative study Thassanee Soontorn a,∗ , Praditporn Pongtriang a , Praneed Songwathana b a b
Faculty of Nursing, Suratthani Rajabhat University, Suratthani 84100, Thailand Faculty of Nursing, Prince of Songkla University, Songkla 90110, Thailand
a r t i c l e
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Article history: Received 6 August 2019 Received in revised form 25 November 2019 Accepted 25 November 2019 Keywords: Dependent elders Emergency illness Family caregiver Qualitative study
a b s t r a c t Aim: To describe the experience of family caregivers of dependent elders during medical emergencies in rural settings in Thailand. Methods: This was a descriptive qualitative research using in-depth interviews of 15 participants. Content analysis was applied to transcribed interviews, including data reduction as well as identification of key words, phrases, and themes. Results: The findings described the experience of caregivers of dependent older persons who faced emergency illness. Most of the family caregivers described their roles in unusual situations as practising assessment first and doing something that may relieve the symptoms experienced by the older persons before initiating and calling for help from relatives, neighbors, and, finally, the emergency medical services. The caregivers four main barriers to them feeling competent: (1) lack of home monitoring devices, (2) inexperienced caregivers in assessing warning signs to report during emergency care, (3) lack of information and understanding of patient rights in emergency health services, and (4) delayed arrival of emergency medical services. Conclusions: There are barriers to the development of competency in caregiving skills, especially in assessing and recognizing warning signs and initiating first aid accurately before the arrival of the emergency health care team. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Introduction In 2017, the percentage of Thai population aged 60 years and above was reported to be approximately 16.9 by the UN; by 2021, Thailand will enter the aged society (in which more than 14% of the net population are aged 65 years and above), and a decade later, it will become a super-aged society (wherein approximately 20% of the total population are aged 60 years and above) [1]. Age is generally associated with deteriorating health over the long term, and most elders need assistance at some point for some activities. An older person who needs other people to take care of them in their daily life activities is referred to as a “dependent older person” [2]. Serious health policy implications are raised by the demographic trends expected in Thailand, and the rapidly increasing demand for care giving for dependent elders will likely outpace available
∗ Corresponding author. E-mail addresses: [email protected] (T. Soontorn), [email protected] (P. Pongtriang), [email protected] (P. Songwathana).
resources. Family caregivers play an important role not only in supporting the routines of the dependent elders but also in helping during worsening or critical situations associated with various problems in acute care [3]. Family caregiving expectations are more intensive, complex, and judgment-laden than those in the past, and family caregivers only intermittently receive adequate training for their role [4]. The Thai Ministry of Public Health policy for emergency medical care currently provides emergency services covering elderly people in remote areas [5]. Elderly patients with emergency illness are prioritized: they must have safe and easy access to appropriate hospital facilities and medical intervention. During the assessment of caregiver needs, including and discussing dependent elders and caregiver views is essential, along with explaining illness factors and available services, called emergency medical services (EMS). The role of a caregiver is important not only in supporting routine care for dependent elders but also in helping in the situations that constitute health emergencies. Responsible and competent caregivers can greatly facilitate the effectiveness of prehospital emergency care, such as accessing patient information and history;
https://doi.org/10.1016/j.auec.2019.11.002 2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Soontorn T, et al. Thai family caregivers’ experiences helping dependent elders during medical emergencies: a qualitative study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.11.002
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therefore, EMS providers can make better clinical decisions when rendering care [6]. Several gaps exist in the hospital and community interface (prehospital phase) with regard to caregiver needs and skills in caring for dependent older people. In the traditions of rural communities in Thailand, the main caregivers for dependent older people are typically inconsistent, as extended family members assume the role at varying times, and the caregiving response begins when dependency is first noticed and care needs are identified [7]. Consequently, it is difficult to guarantee that the people who receive education in home care from health professionals are necessarily the same personnel who actually administer dependent care at home. Along with incorporating older people’s caregivers in care planning and provision, it is important to recognize their capacities for emergency preparedness and response as prerequisites of home-based care. In emergency or critical health situations, caregivers’ readiness to provide aspects of emergency care is essential to improve patient outcomes; thus, it is necessary to assess caregivers’ readiness for emergency care management in such roles. This study investigates caring experiences and barriers perceived by family caregivers in their care for dependent older people during emergency illness to provide evidence to inform future care initiatives to support family caregivers with appropriate emergency management for the health of dependent elders at home.
Ethical considerations
Methods
This research was approved by the Humans Research Ethics Committees, Suratthani Rajabhat University (project code SRU A 009/2560). Before the interview process or beginning any fieldwork, the chief executive of a sub-district administrative organization gave permission to recruit potential caregivers from an official lists of cases of dependent elderly people. The information statement was provided to the potential participants to ensure that all participants understood the nature of the research project and all of their rights as voluntary participants before signing the consent form. The research involved interviews, which were digitally audio-recorded (with participants’ permission). Before conducting interviews, the researcher clarified the nature of the study and participants’ rights, and the interviews commenced with full informed consent from participants. During the face-to-face interviews, if participants felt uncomfortable about answering some questions, then the researchers would stop the recording and resume after re-confirming permission. Participants were informed of their right to withdraw from the research at any time and that their statutory rights and the care they received would not be affected in any way. They were informed that raw data from this research will be destroyed at the end of the study. Codes were used to record and identify clinically pertinent demographic information on an anonymous basis, while maintaining the absolute confidentiality of participants, preventing any potential harms due to disclosure in the event of lost or stolen audio recordings or other interview data.
Design
Data collection
This descriptive qualitative research study investigated the experience of family caregivers in managing care for dependent elders. To achieve the aim of this research, the researchers had attended the workshop and prepared skills in conducting an interview and analysis process in qualitative research.
Data were collected between May and December 2017. Researchers contacted the chief executive of a sub-district administrative organization to explain the study objectives, timeframe, and general procedures of participants. The field staff of Social Development and Human Security personnel departments was assigned to join with the researchers for guiding and providing the information in relation to a possible participant. The demographic data of dependent elders were collected from the health records to understand the emergency illness. After participants agreed to join the study, they were invited to sign the consent forms and were asked to complete the short form of the demographic data such as age and occupation before the interview process. Individual participants were interviewed at least once as in face-to-face interviews, each of which took approximately 45–60 min. Open-ended questions were used in the in-depth interviews to investigate participants’ experiences in assisting in the care of elders during serious illness or from accidents starting at the scene and the procedures of first aid up until arrival at the emergency room. Six questions were asked to determine the barriers of caregivers when caring for dependent elders during emergency health care situations (Table 1). All questions were reviewed for accuracy of content and were edited by three experts, with two being experienced in spatial research and one being an expert in qualitative research.
Setting and participants The study setting was nine villages in Trang Province, Southern Thailand, managed by a local sub-district administrative organization). Potential caregivers were identified from a dependent elder list in the “Elderly Registration Book” administered by the local authorities at the time of the study (May 2017). This publicly accessible information was used to source the contact information for 113 dependent older people and their family caregivers, which provided the means for contacting them to invite a purposive sample to participate. The local government defined dependent elders as those aged 60 years and above with a Barthel Activities of Daily Living (Barthel ADL) index score of less than 12; the total possible Barthel ADL scores range from 0 to 20, with lower scores indicating increased disability [8]. The purposively sampled caregivers had at least six months’ experience as caregivers and had experience in helping elders during emergency illness. Possible inclusion criteria for participants were discussed with the officers in the sub-district administrative organization before approaching the family carers to check their eligibility to participate and to seek their informed consent after a comprehensive discussion and explanation of the study purposes, their rights (particularly the right to withdraw), and the voluntary nature of their participation. Fifteen participants were approached by the researcher and an initial explanation was given about the study for them to make a decision about their involvement. All agreed to participate, and pleased to have the opportunity to share their views.
Data analysis Interviews were subsequently transcribed, and the data provider validated the resultant information. The research data were collected in Thai language and were then translated into English by a professional translator. Subsequently, the English transcriptions were reviewed for accuracy by the research team. In addition, both Thai and English transcriptions were reviewed by an expert in emergency care and qualitative research to ensure the consistency of language. The data were analyzed by content
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R1: Please describe your experiences in assisting of the elder during serious illness or from accidents. . . starting at the scene, and the procedures of first aid up until arrival at the emergency room. R2: How did you handle of the elder who facing serious illness, such as being acutely ill or injured? R3: Did you call for help from friends, neighbors, and/or community leaders, or EMS? How did you make a decision? R4: Please identify your needs or comments when an emergency illness occurs in elders at home? For example, could you access the EMS? What was a response, and what do you think about that?
analysis, and the six steps mentioned by Creswell (2013) were followed to categorize and classify the repetition of words, phrases, sentences, and paragraphs into codes and themes [9]. All codes and themes were reviewed by the research team for confirmation of content and member checking. These triangulation processes ensure the rigor of the analysis undertaken in the research project. Emerging codes and themes were then considered for interpretation and answer the research questions. The categories were identified as caregivers’ management and their barriers, which emerged from the reported experiences of participants. Results The research results start with addressing the demographics data of the caregivers and then the reported experiences of managing care of dependent elders during emergency illness. Demographic data of the informants and the dependent elders The caregiver sample comprised 15 cases, all of whom were females. Their mean age was 49.00 years (SD ± 14.07 years), with a range of 30–77 years. All the caregivers were closely related to the patients; nearly 90% were daughters (13 of 15) and 2 (%) of 15 were a wife and a niece of dependent elders. Almost 80% (n = 12) were rubber farmers, two of them had no occupation, and one was a wage-worker. The participants had taken dependent elders within Barthel-ADL index scores ranging from 5 to 11 and who had more than one chronic illness such as diabetes, hypertension, old myocardial infarction, cerebral infarction, and hemorrhagic stroke. In terms of health benefits, all dependent elders had universal coverage consisting of two categories: 13 had the elderly welfare scheme (‘Aging Golden Card’), while two had a Government Officer Scheme Card through their sons or daughters, who were not their family caregivers. Experiences of family caregivers in their management and barriers Two main themes were identified under the experiences of caregivers in managing care of dependent elders during emergency illness. Management of elder’s symptoms by themselves before calling for help The findings indicated that the first responders to emergency illness were family members assuming the caregiver role. Most of these caregivers described their roles in emergency situations as practicing assessment first and doing something at home to relieve the immediate symptoms experienced by the dependent people before initiating and calling for help from relatives, neighbors, and,
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finally, the EMS. For example, the following participant discussed the chronology of how she dealt with the emergency illness of her father: “When I noticed that my father was becoming sick. . . He was convulsing and laid unconscious on the ground. He stopped convulsing on his own though. I asked my nephew to rub him all over and gave him inhalant. When he was conscious, then we gave him some liquid medicine to drink. We didn’t think he needed the doctor. A while later, his arms and legs started to contract. His eyes rolled back. My nephew asked me to take my father to see the doctor, so I called my younger brother to take our father to the doctor” (Case 01) This participant explained that when an emergency illness occurred with a family member, the first decision was the way to relieve those symptoms before asking for assistance from people nearby, such as relatives or neighbors. The participant’s reflection revealed that the last call for aid was health care services. Another participant talked about how she managed and assisted her husband during a medical emergency: “My husband appeared to be tired and breathed heavily. Even after a couple of doses of nasal sprays, he still appeared to be tired. He was stubborn and said it was normal for him and he wanted to wait and see, then his breathing was bad, about ten minutes after his nephew’s 1669 call” (Case 08) This caregiver reflected that confronting a situation of medical illness in a family member required monitoring and evaluation before making an emergency call. Management of apparent symptoms was seen as the first responsibility in assisting patients at home. Barriers to optimum management The caregivers described four main barriers to performing the optimum management of the emergency cases in caring for dependent elders: (1) lack of home monitoring devices, (2) inexperience in assessing warning signs to report during emergency care, (3) lack of information and understanding of patient rights in emergency health services, and (4) delayed arrival of EMS. Lack of home monitoring devices. Participants reported that the homes of dependent elders lacked medical equipment for assessing abnormalities, such as blood pressure monitors, blood glucose meters, and alarm monitoring. Most participants were not able to tell the early signs of symptoms that worsened at later points, and some caregivers reflected on their slow decisions to take the patients to health professionals, which, in turn, resulted in delayed emergency and general care for the dependent elders. This was exemplified by the following participant: “. . . She [mother] complained about her headache before worsening. Mom was taking a nap from late morning until noon. When I tried to wake her up, her eyes were open, but she was not talking, then I called the ambulance. The hospital staff asked me what her symptoms were like. I said I didn’t know. The nurse then said my account affects the treatment. So I informed them of what I had seen. The doctor once said that if she gets a headache then I should measure her blood pressure, to monitor the high blood pressure. I wanted to, but I couldn’t because I had no equipment. Usually, the village volunteer came to measure her blood pressure once a month” (Case 02) Participants in this study rarely performed dependent care completely autonomously, and they preferred to actively look for tools and other resources such as the “village volunteer” alluded to in the previous example. On the other hand, some participants viewed the Emergency Department as a safety net for the health system, but
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many believed that patients with advanced disease should have alternative options as exemplified by the following participant: “My husband appeared to be tired, and was breathing heavily. Even after a couple of doses of nasal sprays, he still appeared to be tired. I called my nephew to take him to the hospital. He was stubborn and said it was normal for him and he wanted to wait and see. I believe if we had an oximeter pulse, like the one you find at the hospital, then it would have been a good parameter for decision making earlier. At least we would know whether it was better or worse for him after he used the nasal spray” (Case 08) Ethically, according to healthcare providers, patients have the right to make decisions regarding their medical treatment, but they may need to consider other caregiving alternatives if the burden of these decisions is too much for the family caregivers. Inexperience in assessing warning signs to report during emergency care. All of the dependent elders in this study had common illnesses, with at least one chronic disease for each person. Caregivers’ rapid responses included using the telephone as a tool for communication to seek assistance when they were faced with an emergency or injury. Some of them exchanged knowledge with their neighbors when assessing patient condition and making decisions concerning particular symptoms. ". . . Mum probably took some pills what unknown type and dosage. . . she was drowsy and uncomfortable. . . then I called other family members to let them know and waited for them to come here. . . before taking her [the patient] to the hospital. . ." (Case 13) “. . . She complained a sudden chest pain, felt discomfort. . . when I hurriedly called my sister, after about half an hour we arrived at the emergency room. . . I remember that the doctor ¨ 06) said ‘patient shocked’(Case Most participants attributed problems to lack of knowledge on variance in abnormal symptoms, awareness of the abnormalities, and assessment of the level of severity of the illness or injury. Some participants reflected that wrong judgment leads to bad decision making, which in turn results in more complicated outcomes. Other caregivers showed signs of concern by their facial expressions and told their accounts of their stories with shaken voices as in the following examples: “Many times that night, my mother’s waste [bowel movement] was all liquid. She vomited three times. I tried to get her to sit up to drink liquid medicine and I provided inhalant for her. I thought she was better. I was thinking of what I should do. I decided to let my mother lie down. Later in the morning on the next day, my neighbor told us to take my mother to the hospital. Once we got there, the doctor said that she was inactive due to her low blood pressure and had to be hospitalized” (Case 03) Various levels of barriers were reported by participants that influenced their decision-making and the use of unusual caregiving methods. This study found some cases in which warning signs indicating relatively severe symptoms were assessed as being nonthreatening; consequently, the dependent elders who sustained disease progression were not transported to hospital in time. Some rural caregivers explained that they suffered because of their assessment mistakes because of lack of knowledge and skills in emergency care abilities. Participants reported that their flawed decision-making led to delays in the provision of definitive care for dependent elders as in the following example: “Normally I gave one tablet of cathartic [administered for constipation over 2–3 days] before bed, but on that night, I gave
him two tablets because he hadn’t used the bathroom for three days. When he let out lots of waste, I was scared that he might pass away. I called my sister who was nearby and told her that dad might be in shock. I called the sub-district headman and my children who live in another province. I was relieved when we arrived at the hospital and we assumed that ‘would be okay’ unless he subsequently died (Case 04) Lack of information and understanding of patient rights in emergency health services. Many of the caregivers interviewed were themselves elders, and some were not as open to receive information or were not enthusiastic to search for information on patient rights in receiving medical treatment, as well as the welfare as provided by the government. Most of the participants did not search for information on their own. They mentioned the social workers of their villages who came to visit and provided the information at home and then coordinated for all dependent elders in the village to receive their rights in accordance with the monthly welfare for elders and dependent elders. Participants usually heard about their rights to receive treatment from the television and through their neighbors. The information they received was often contradictory, creating confusion and leading to the fear of fighting for their rights, and being castigated as undeserving of their healthcare rights, as exemplified by the following participants: “My grandmother said she had chest pain. The doctor’s medicine didn’t help her condition. I took her on the motorbike straight to the hospital. It took almost half an hour due to the distance [about 12 km]. The doctor complained about why we went there on our own, as she was in bad shape, and that we should have called an emergency service, when the phone number was on her patient card. There was an announcement about this on TV as well, but I never paid attention. I admit that I didn’t understand it well, and whether I had to pay more money that I didn’t have, or take any further action” (Case 06) The next exemplar described the confusion of health care coverage that led the dependent older person losing the benefit of the right to be covered: “My mother was hospitalized for many days. The doctor informed my brother that it could have been an overdose of diabetic medicines, so she passed out. I wasn’t sure about this though. I only remembered that I was home alone and I tried to call and woke her up, but she just lay still. I gave her a sweetened drink because she has diabetes. She wasn’t fully conscious. I called my younger brother first, because my mother used the civil servant rights [government health insurance] of my brother, a teacher. When she was sick, he had to take her to the hospital himself, so this right could be used. The payment wasn’t needed” (Case 07) Another participant addressed the negative experience she faced with blame by surrounding people when she needed professional assistance during an emergency. This influenced her family and caused them to avoid seeking any help from others: “I was disgraced when I requested an ambulance. Someone blamed my family for being poor. I often heard that other people were also faced with emergency illness, not only my grandpa. Nowadays, checking abnormal health for signs of a struggle or any warning signs that he has been harmed, I prefer to buy medication at a drug store rather than see the doctor. His feet swelling, less urine, he hasn’t been able to walk for about two months [points to patient’s leg]” (Case 12)
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Delayed arrival of emergency medical services. The caregivers reported negative experiences of requesting EMS by calling 1669 (the equivalent to “911” in the US), and delayed response. The landscape of the area is in parts hilly, and in others, lowland. The majority of the area is mountains and forests. In general, there are uncomfortable lanes and some unpaved roads. Moreover, the distance between rural villages and EMS centers are approximately 14–20 km. When the dependent elders required medical attention due to emergency illness, the caregivers often mentioned the word “distress,” as in the following example: “My mother said she feels uncomfortable [the patient had a known case of myocardial infarction with atrial fibrillation]. The doctor’s medicine helped her condition at first, then it started again. We called 1669 to take us there, because my house is so far away from EMS Center, about 20 km’ distance. My younger brother came before the EMS car then he took mom to the hospital. I realized the danger on that day, I was so distressed. I thought about a lot of things and did not know when she would pass out. I just felt it would be safe once we arrived at the hospital” (Case 14) Some conflicts between emergency health service responders and caregivers emerged. The capacity to make informed judgments when assessing the severity of illness of healthcare providers was clearly lacking, judging from caregivers’ experiences and perspectives. Most caregivers requested other relatives to assist their dependent elders accordingly and did not feel they were taken seriously or valued by the health system as in the following case: “. . .I called 1669 and informed them of the situation as concisely as possible for EMS. . . They said do not worry, it is not an emergency, please wait. . . calm down and wait. . . They did not ignore me but I couldn’t wait for. . . if relatives came before. . . delayed EMS arrival, I believe that among relatives there is more concern and we are not overlooked” (Case 05) Therefore, barriers existed in the dimension of intermediate care in community settings, with older people and their caregivers waiting and worrying about what was wrong in the context of time pressures and lack of attention to their basic needs, with poor relationships and interactions with health professionals leading to feeling ignored, forgotten, and unimportant.
Discussion Most caregivers reported that they were unable to effectively respond to various health problems among dependent elders in the rural communities of Thailand as exhibited by caregiver perceptions during episodes of dependent older person emergency illness before arrival at hospitals. Providing for the healthcare expectations of patients is affected by positive and negative caregiver impacts on the basis of their knowledge and skills, views, perceptions, and experiences of patients, patient conditions, and health services. Rural caregivers in lower-middle-income countries generally face shortages in resources and poor emergency health care system responses [7,10]. In this study, all families described that inefficient management of emergency cases was related to lack of home monitoring devices for arterial oxygen saturation blood pressure, and capillary blood glucose used to determine the onset time of clinical changes. Some studies have provided evidence supporting the effectiveness of caregiver preparedness in supporting the acute health care system, particularly in terms of using medical monitoring devices such as sensors to monitor the health indicators of elderly and disabled patients, providing them with service-oriented emergency responses in real time for abnormal health condition cases [11–13].
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Some caregivers reported conflicts about treatment decisions stemming from disagreements about treatment risks or goals or from the implications of treatments for their care provision. Inability to understand the implications of patients’ biomedical conditions is a barrier to caregiver forecasting for elders requiring chronic care [14]. For example, certain complex, commonly underappreciated symptoms and signs among older patients with chronic respiratory disease include voice/speaking problems, urinary incontinence, and worsening confusion. Moreover, medication mismanagement is a growing public health concern, especially among elders. Caregivers often continue to administer and prescribe increasingly frequent medication and/or larger doses, without really judging whether the medications remain effective after long periods of use or other possible interactions [15]. Therefore, the common disease patterns of chronic diseases should be explained to family caregivers, with improved resources to help caregivers anticipate and manage acute care needs [16]. Poorer caregiver outcomes result from inadequate preparations for the caregiving role and collaboration with health professionals for skills training, communication, and resource identification and activation [17]. This study found that informal caregivers in chronic care cases call for more involvement of EMS for improved collaboration in acute health care provision. With regard to collaboration in acute health care, caregivers commonly experience anxiety and uncertainty with concerns over communication, the general environment, delays in symptoms management, and long waiting times for services, although patients and caregivers describe great relief and satisfaction when they finally receive care [18]. Other issues included the negative experiences of caregivers in requesting EMS, including delays, which is a common issue in remote areas in Thailand because of insufficient medical personnel and equipment. Similarly, a study in Namibia found that elderly patients also experienced transport delays, especially in the case of emergencies, and they felt that transport was available, but it was not for their use [19]. Delays in response are natural outcomes when demand outstrips available resources, and health personnel can be delayed at any of the transitional stages from site to hospital because of geographical, traffic, or case-related situations and the complexity of assessing and referring patients [20]. By definition, emergencies can occur at any time in emergency medicine, and new onsets (red flags) such as severe headaches or “worst headache of life” should be evaluated for potential disabling or life-threatening diagnoses. Emergency healthcare providers need to be aware of red flags in patient history and understand examinations that point toward serious underlying causes [21]. If the condition of the patient worsens, caregivers should be able to respond to questions concerning the time of the beginning of clinical changes and/or what characteristics indicated disease progression [22].
Conclusions The findings revealed that family caregivers face serious challenges in managing emergency conditions among dependent older people, including functional decline, and lack of medical equipment and training which affected decision-making processes and resulted in the delay of definitive care provision in many cases. Most participants prefer to call family members for guidance to solve any serious problems during medical emergencies, slowing reactions to sudden deteriorations within the milieu of their experiences and resources. Caregivers viewed the process of healing as complete if the elder felt better or their condition stabilized. However, for dependent elders suffering from deterioration and requiring professional evaluation and treatment, some family caregivers took them to nearby hospitals by private car and others
Please cite this article in press as: Soontorn T, et al. Thai family caregivers’ experiences helping dependent elders during medical emergencies: a qualitative study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.11.002
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requested EMS indirectly by other people such as neighbors or community leaders. There was a notable aversion to utilizing healthcare professional resources in the first instance, and they were generally regarded as the last resort. In addition, response times and the transitional process from the scene to definitive care in hospitals seemed to have barriers in remote areas. Therefore, there is a need in health systems to reform the integration between acute health care and long-team care for dependent elders, which is particularly important in the increasing growth of older people for the aging society. What is already known on this topic Existing research has revealed the significance of developing emergency health care systems in the prehospital phase for dependent older persons. There is little known regarding the experience of caregivers in managing care during medical emergency, particularly in the context of Thailand. What this study adds Most caregivers were able to manage by themselves before calling for emergency assistance. Caregivers reported several barriers when attending dependent older persons with an emergency condition in a rural community. Caregivers require specific skills especially in assessing and recognizing warning signs and initiating first aid appropriately before emergency health care team activation. With an aging society, greater improvement in prehospital services in emergency systems for home- and community-based long-term care is necessary. Provenance and conflicts of interest The authors certify that this study has neither been published in whole nor in part elsewhere, nor is it under consideration elsewhere. The authors also declare that there are no conflicts of interest regarding the publication of this paper. Acknowledgments The authors would like to deeply thank all of the dependent elders and their families who participated in this study. This research project was partially sponsored by the Research and Development Institute, Suratthani Rajabhat University and the Thai Health Promotion Foundation.
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References [1] United Nations. World population aging 2017. Department of economic and social affairs population division. New York: United Nations; 2017. p. 107.
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Research paper
Thai family caregivers’ experiences helping dependent elders during medical emergencies: a qualitative study Thassanee Soontorn a,∗ , Praditporn Pongtriang a , Praneed Songwathana b a b
Faculty of Nursing, Suratthani Rajabhat University, Suratthani 84100, Thailand Faculty of Nursing, Prince of Songkla University, Songkla 90110, Thailand
a r t i c l e
i n f o
Article history: Received 6 August 2019 Received in revised form 25 November 2019 Accepted 25 November 2019 Keywords: Dependent elders Emergency illness Family caregiver Qualitative study
a b s t r a c t Aim: To describe the experience of family caregivers of dependent elders during medical emergencies in rural settings in Thailand. Methods: This was a descriptive qualitative research using in-depth interviews of 15 participants. Content analysis was applied to transcribed interviews, including data reduction as well as identification of key words, phrases, and themes. Results: The findings described the experience of caregivers of dependent older persons who faced emergency illness. Most of the family caregivers described their roles in unusual situations as practising assessment first and doing something that may relieve the symptoms experienced by the older persons before initiating and calling for help from relatives, neighbors, and, finally, the emergency medical services. The caregivers four main barriers to them feeling competent: (1) lack of home monitoring devices, (2) inexperienced caregivers in assessing warning signs to report during emergency care, (3) lack of information and understanding of patient rights in emergency health services, and (4) delayed arrival of emergency medical services. Conclusions: There are barriers to the development of competency in caregiving skills, especially in assessing and recognizing warning signs and initiating first aid accurately before the arrival of the emergency health care team. © 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Introduction In 2017, the percentage of Thai population aged 60 years and above was reported to be approximately 16.9 by the UN; by 2021, Thailand will enter the aged society (in which more than 14% of the net population are aged 65 years and above), and a decade later, it will become a super-aged society (wherein approximately 20% of the total population are aged 60 years and above) [1]. Age is generally associated with deteriorating health over the long term, and most elders need assistance at some point for some activities. An older person who needs other people to take care of them in their daily life activities is referred to as a “dependent older person” [2]. Serious health policy implications are raised by the demographic trends expected in Thailand, and the rapidly increasing demand for care giving for dependent elders will likely outpace available
∗ Corresponding author. E-mail addresses: [email protected] (T. Soontorn), [email protected] (P. Pongtriang), [email protected] (P. Songwathana).
resources. Family caregivers play an important role not only in supporting the routines of the dependent elders but also in helping during worsening or critical situations associated with various problems in acute care [3]. Family caregiving expectations are more intensive, complex, and judgment-laden than those in the past, and family caregivers only intermittently receive adequate training for their role [4]. The Thai Ministry of Public Health policy for emergency medical care currently provides emergency services covering elderly people in remote areas [5]. Elderly patients with emergency illness are prioritized: they must have safe and easy access to appropriate hospital facilities and medical intervention. During the assessment of caregiver needs, including and discussing dependent elders and caregiver views is essential, along with explaining illness factors and available services, called emergency medical services (EMS). The role of a caregiver is important not only in supporting routine care for dependent elders but also in helping in the situations that constitute health emergencies. Responsible and competent caregivers can greatly facilitate the effectiveness of prehospital emergency care, such as accessing patient information and history;
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therefore, EMS providers can make better clinical decisions when rendering care [6]. Several gaps exist in the hospital and community interface (prehospital phase) with regard to caregiver needs and skills in caring for dependent older people. In the traditions of rural communities in Thailand, the main caregivers for dependent older people are typically inconsistent, as extended family members assume the role at varying times, and the caregiving response begins when dependency is first noticed and care needs are identified [7]. Consequently, it is difficult to guarantee that the people who receive education in home care from health professionals are necessarily the same personnel who actually administer dependent care at home. Along with incorporating older people’s caregivers in care planning and provision, it is important to recognize their capacities for emergency preparedness and response as prerequisites of home-based care. In emergency or critical health situations, caregivers’ readiness to provide aspects of emergency care is essential to improve patient outcomes; thus, it is necessary to assess caregivers’ readiness for emergency care management in such roles. This study investigates caring experiences and barriers perceived by family caregivers in their care for dependent older people during emergency illness to provide evidence to inform future care initiatives to support family caregivers with appropriate emergency management for the health of dependent elders at home.
Ethical considerations
Methods
This research was approved by the Humans Research Ethics Committees, Suratthani Rajabhat University (project code SRU A 009/2560). Before the interview process or beginning any fieldwork, the chief executive of a sub-district administrative organization gave permission to recruit potential caregivers from an official lists of cases of dependent elderly people. The information statement was provided to the potential participants to ensure that all participants understood the nature of the research project and all of their rights as voluntary participants before signing the consent form. The research involved interviews, which were digitally audio-recorded (with participants’ permission). Before conducting interviews, the researcher clarified the nature of the study and participants’ rights, and the interviews commenced with full informed consent from participants. During the face-to-face interviews, if participants felt uncomfortable about answering some questions, then the researchers would stop the recording and resume after re-confirming permission. Participants were informed of their right to withdraw from the research at any time and that their statutory rights and the care they received would not be affected in any way. They were informed that raw data from this research will be destroyed at the end of the study. Codes were used to record and identify clinically pertinent demographic information on an anonymous basis, while maintaining the absolute confidentiality of participants, preventing any potential harms due to disclosure in the event of lost or stolen audio recordings or other interview data.
Design
Data collection
This descriptive qualitative research study investigated the experience of family caregivers in managing care for dependent elders. To achieve the aim of this research, the researchers had attended the workshop and prepared skills in conducting an interview and analysis process in qualitative research.
Data were collected between May and December 2017. Researchers contacted the chief executive of a sub-district administrative organization to explain the study objectives, timeframe, and general procedures of participants. The field staff of Social Development and Human Security personnel departments was assigned to join with the researchers for guiding and providing the information in relation to a possible participant. The demographic data of dependent elders were collected from the health records to understand the emergency illness. After participants agreed to join the study, they were invited to sign the consent forms and were asked to complete the short form of the demographic data such as age and occupation before the interview process. Individual participants were interviewed at least once as in face-to-face interviews, each of which took approximately 45–60 min. Open-ended questions were used in the in-depth interviews to investigate participants’ experiences in assisting in the care of elders during serious illness or from accidents starting at the scene and the procedures of first aid up until arrival at the emergency room. Six questions were asked to determine the barriers of caregivers when caring for dependent elders during emergency health care situations (Table 1). All questions were reviewed for accuracy of content and were edited by three experts, with two being experienced in spatial research and one being an expert in qualitative research.
Setting and participants The study setting was nine villages in Trang Province, Southern Thailand, managed by a local sub-district administrative organization). Potential caregivers were identified from a dependent elder list in the “Elderly Registration Book” administered by the local authorities at the time of the study (May 2017). This publicly accessible information was used to source the contact information for 113 dependent older people and their family caregivers, which provided the means for contacting them to invite a purposive sample to participate. The local government defined dependent elders as those aged 60 years and above with a Barthel Activities of Daily Living (Barthel ADL) index score of less than 12; the total possible Barthel ADL scores range from 0 to 20, with lower scores indicating increased disability [8]. The purposively sampled caregivers had at least six months’ experience as caregivers and had experience in helping elders during emergency illness. Possible inclusion criteria for participants were discussed with the officers in the sub-district administrative organization before approaching the family carers to check their eligibility to participate and to seek their informed consent after a comprehensive discussion and explanation of the study purposes, their rights (particularly the right to withdraw), and the voluntary nature of their participation. Fifteen participants were approached by the researcher and an initial explanation was given about the study for them to make a decision about their involvement. All agreed to participate, and pleased to have the opportunity to share their views.
Data analysis Interviews were subsequently transcribed, and the data provider validated the resultant information. The research data were collected in Thai language and were then translated into English by a professional translator. Subsequently, the English transcriptions were reviewed for accuracy by the research team. In addition, both Thai and English transcriptions were reviewed by an expert in emergency care and qualitative research to ensure the consistency of language. The data were analyzed by content
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R1: Please describe your experiences in assisting of the elder during serious illness or from accidents. . . starting at the scene, and the procedures of first aid up until arrival at the emergency room. R2: How did you handle of the elder who facing serious illness, such as being acutely ill or injured? R3: Did you call for help from friends, neighbors, and/or community leaders, or EMS? How did you make a decision? R4: Please identify your needs or comments when an emergency illness occurs in elders at home? For example, could you access the EMS? What was a response, and what do you think about that?
analysis, and the six steps mentioned by Creswell (2013) were followed to categorize and classify the repetition of words, phrases, sentences, and paragraphs into codes and themes [9]. All codes and themes were reviewed by the research team for confirmation of content and member checking. These triangulation processes ensure the rigor of the analysis undertaken in the research project. Emerging codes and themes were then considered for interpretation and answer the research questions. The categories were identified as caregivers’ management and their barriers, which emerged from the reported experiences of participants. Results The research results start with addressing the demographics data of the caregivers and then the reported experiences of managing care of dependent elders during emergency illness. Demographic data of the informants and the dependent elders The caregiver sample comprised 15 cases, all of whom were females. Their mean age was 49.00 years (SD ± 14.07 years), with a range of 30–77 years. All the caregivers were closely related to the patients; nearly 90% were daughters (13 of 15) and 2 (%) of 15 were a wife and a niece of dependent elders. Almost 80% (n = 12) were rubber farmers, two of them had no occupation, and one was a wage-worker. The participants had taken dependent elders within Barthel-ADL index scores ranging from 5 to 11 and who had more than one chronic illness such as diabetes, hypertension, old myocardial infarction, cerebral infarction, and hemorrhagic stroke. In terms of health benefits, all dependent elders had universal coverage consisting of two categories: 13 had the elderly welfare scheme (‘Aging Golden Card’), while two had a Government Officer Scheme Card through their sons or daughters, who were not their family caregivers. Experiences of family caregivers in their management and barriers Two main themes were identified under the experiences of caregivers in managing care of dependent elders during emergency illness. Management of elder’s symptoms by themselves before calling for help The findings indicated that the first responders to emergency illness were family members assuming the caregiver role. Most of these caregivers described their roles in emergency situations as practicing assessment first and doing something at home to relieve the immediate symptoms experienced by the dependent people before initiating and calling for help from relatives, neighbors, and,
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finally, the EMS. For example, the following participant discussed the chronology of how she dealt with the emergency illness of her father: “When I noticed that my father was becoming sick. . . He was convulsing and laid unconscious on the ground. He stopped convulsing on his own though. I asked my nephew to rub him all over and gave him inhalant. When he was conscious, then we gave him some liquid medicine to drink. We didn’t think he needed the doctor. A while later, his arms and legs started to contract. His eyes rolled back. My nephew asked me to take my father to see the doctor, so I called my younger brother to take our father to the doctor” (Case 01) This participant explained that when an emergency illness occurred with a family member, the first decision was the way to relieve those symptoms before asking for assistance from people nearby, such as relatives or neighbors. The participant’s reflection revealed that the last call for aid was health care services. Another participant talked about how she managed and assisted her husband during a medical emergency: “My husband appeared to be tired and breathed heavily. Even after a couple of doses of nasal sprays, he still appeared to be tired. He was stubborn and said it was normal for him and he wanted to wait and see, then his breathing was bad, about ten minutes after his nephew’s 1669 call” (Case 08) This caregiver reflected that confronting a situation of medical illness in a family member required monitoring and evaluation before making an emergency call. Management of apparent symptoms was seen as the first responsibility in assisting patients at home. Barriers to optimum management The caregivers described four main barriers to performing the optimum management of the emergency cases in caring for dependent elders: (1) lack of home monitoring devices, (2) inexperience in assessing warning signs to report during emergency care, (3) lack of information and understanding of patient rights in emergency health services, and (4) delayed arrival of EMS. Lack of home monitoring devices. Participants reported that the homes of dependent elders lacked medical equipment for assessing abnormalities, such as blood pressure monitors, blood glucose meters, and alarm monitoring. Most participants were not able to tell the early signs of symptoms that worsened at later points, and some caregivers reflected on their slow decisions to take the patients to health professionals, which, in turn, resulted in delayed emergency and general care for the dependent elders. This was exemplified by the following participant: “. . . She [mother] complained about her headache before worsening. Mom was taking a nap from late morning until noon. When I tried to wake her up, her eyes were open, but she was not talking, then I called the ambulance. The hospital staff asked me what her symptoms were like. I said I didn’t know. The nurse then said my account affects the treatment. So I informed them of what I had seen. The doctor once said that if she gets a headache then I should measure her blood pressure, to monitor the high blood pressure. I wanted to, but I couldn’t because I had no equipment. Usually, the village volunteer came to measure her blood pressure once a month” (Case 02) Participants in this study rarely performed dependent care completely autonomously, and they preferred to actively look for tools and other resources such as the “village volunteer” alluded to in the previous example. On the other hand, some participants viewed the Emergency Department as a safety net for the health system, but
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many believed that patients with advanced disease should have alternative options as exemplified by the following participant: “My husband appeared to be tired, and was breathing heavily. Even after a couple of doses of nasal sprays, he still appeared to be tired. I called my nephew to take him to the hospital. He was stubborn and said it was normal for him and he wanted to wait and see. I believe if we had an oximeter pulse, like the one you find at the hospital, then it would have been a good parameter for decision making earlier. At least we would know whether it was better or worse for him after he used the nasal spray” (Case 08) Ethically, according to healthcare providers, patients have the right to make decisions regarding their medical treatment, but they may need to consider other caregiving alternatives if the burden of these decisions is too much for the family caregivers. Inexperience in assessing warning signs to report during emergency care. All of the dependent elders in this study had common illnesses, with at least one chronic disease for each person. Caregivers’ rapid responses included using the telephone as a tool for communication to seek assistance when they were faced with an emergency or injury. Some of them exchanged knowledge with their neighbors when assessing patient condition and making decisions concerning particular symptoms. ". . . Mum probably took some pills what unknown type and dosage. . . she was drowsy and uncomfortable. . . then I called other family members to let them know and waited for them to come here. . . before taking her [the patient] to the hospital. . ." (Case 13) “. . . She complained a sudden chest pain, felt discomfort. . . when I hurriedly called my sister, after about half an hour we arrived at the emergency room. . . I remember that the doctor ¨ 06) said ‘patient shocked’(Case Most participants attributed problems to lack of knowledge on variance in abnormal symptoms, awareness of the abnormalities, and assessment of the level of severity of the illness or injury. Some participants reflected that wrong judgment leads to bad decision making, which in turn results in more complicated outcomes. Other caregivers showed signs of concern by their facial expressions and told their accounts of their stories with shaken voices as in the following examples: “Many times that night, my mother’s waste [bowel movement] was all liquid. She vomited three times. I tried to get her to sit up to drink liquid medicine and I provided inhalant for her. I thought she was better. I was thinking of what I should do. I decided to let my mother lie down. Later in the morning on the next day, my neighbor told us to take my mother to the hospital. Once we got there, the doctor said that she was inactive due to her low blood pressure and had to be hospitalized” (Case 03) Various levels of barriers were reported by participants that influenced their decision-making and the use of unusual caregiving methods. This study found some cases in which warning signs indicating relatively severe symptoms were assessed as being nonthreatening; consequently, the dependent elders who sustained disease progression were not transported to hospital in time. Some rural caregivers explained that they suffered because of their assessment mistakes because of lack of knowledge and skills in emergency care abilities. Participants reported that their flawed decision-making led to delays in the provision of definitive care for dependent elders as in the following example: “Normally I gave one tablet of cathartic [administered for constipation over 2–3 days] before bed, but on that night, I gave
him two tablets because he hadn’t used the bathroom for three days. When he let out lots of waste, I was scared that he might pass away. I called my sister who was nearby and told her that dad might be in shock. I called the sub-district headman and my children who live in another province. I was relieved when we arrived at the hospital and we assumed that ‘would be okay’ unless he subsequently died (Case 04) Lack of information and understanding of patient rights in emergency health services. Many of the caregivers interviewed were themselves elders, and some were not as open to receive information or were not enthusiastic to search for information on patient rights in receiving medical treatment, as well as the welfare as provided by the government. Most of the participants did not search for information on their own. They mentioned the social workers of their villages who came to visit and provided the information at home and then coordinated for all dependent elders in the village to receive their rights in accordance with the monthly welfare for elders and dependent elders. Participants usually heard about their rights to receive treatment from the television and through their neighbors. The information they received was often contradictory, creating confusion and leading to the fear of fighting for their rights, and being castigated as undeserving of their healthcare rights, as exemplified by the following participants: “My grandmother said she had chest pain. The doctor’s medicine didn’t help her condition. I took her on the motorbike straight to the hospital. It took almost half an hour due to the distance [about 12 km]. The doctor complained about why we went there on our own, as she was in bad shape, and that we should have called an emergency service, when the phone number was on her patient card. There was an announcement about this on TV as well, but I never paid attention. I admit that I didn’t understand it well, and whether I had to pay more money that I didn’t have, or take any further action” (Case 06) The next exemplar described the confusion of health care coverage that led the dependent older person losing the benefit of the right to be covered: “My mother was hospitalized for many days. The doctor informed my brother that it could have been an overdose of diabetic medicines, so she passed out. I wasn’t sure about this though. I only remembered that I was home alone and I tried to call and woke her up, but she just lay still. I gave her a sweetened drink because she has diabetes. She wasn’t fully conscious. I called my younger brother first, because my mother used the civil servant rights [government health insurance] of my brother, a teacher. When she was sick, he had to take her to the hospital himself, so this right could be used. The payment wasn’t needed” (Case 07) Another participant addressed the negative experience she faced with blame by surrounding people when she needed professional assistance during an emergency. This influenced her family and caused them to avoid seeking any help from others: “I was disgraced when I requested an ambulance. Someone blamed my family for being poor. I often heard that other people were also faced with emergency illness, not only my grandpa. Nowadays, checking abnormal health for signs of a struggle or any warning signs that he has been harmed, I prefer to buy medication at a drug store rather than see the doctor. His feet swelling, less urine, he hasn’t been able to walk for about two months [points to patient’s leg]” (Case 12)
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Delayed arrival of emergency medical services. The caregivers reported negative experiences of requesting EMS by calling 1669 (the equivalent to “911” in the US), and delayed response. The landscape of the area is in parts hilly, and in others, lowland. The majority of the area is mountains and forests. In general, there are uncomfortable lanes and some unpaved roads. Moreover, the distance between rural villages and EMS centers are approximately 14–20 km. When the dependent elders required medical attention due to emergency illness, the caregivers often mentioned the word “distress,” as in the following example: “My mother said she feels uncomfortable [the patient had a known case of myocardial infarction with atrial fibrillation]. The doctor’s medicine helped her condition at first, then it started again. We called 1669 to take us there, because my house is so far away from EMS Center, about 20 km’ distance. My younger brother came before the EMS car then he took mom to the hospital. I realized the danger on that day, I was so distressed. I thought about a lot of things and did not know when she would pass out. I just felt it would be safe once we arrived at the hospital” (Case 14) Some conflicts between emergency health service responders and caregivers emerged. The capacity to make informed judgments when assessing the severity of illness of healthcare providers was clearly lacking, judging from caregivers’ experiences and perspectives. Most caregivers requested other relatives to assist their dependent elders accordingly and did not feel they were taken seriously or valued by the health system as in the following case: “. . .I called 1669 and informed them of the situation as concisely as possible for EMS. . . They said do not worry, it is not an emergency, please wait. . . calm down and wait. . . They did not ignore me but I couldn’t wait for. . . if relatives came before. . . delayed EMS arrival, I believe that among relatives there is more concern and we are not overlooked” (Case 05) Therefore, barriers existed in the dimension of intermediate care in community settings, with older people and their caregivers waiting and worrying about what was wrong in the context of time pressures and lack of attention to their basic needs, with poor relationships and interactions with health professionals leading to feeling ignored, forgotten, and unimportant.
Discussion Most caregivers reported that they were unable to effectively respond to various health problems among dependent elders in the rural communities of Thailand as exhibited by caregiver perceptions during episodes of dependent older person emergency illness before arrival at hospitals. Providing for the healthcare expectations of patients is affected by positive and negative caregiver impacts on the basis of their knowledge and skills, views, perceptions, and experiences of patients, patient conditions, and health services. Rural caregivers in lower-middle-income countries generally face shortages in resources and poor emergency health care system responses [7,10]. In this study, all families described that inefficient management of emergency cases was related to lack of home monitoring devices for arterial oxygen saturation blood pressure, and capillary blood glucose used to determine the onset time of clinical changes. Some studies have provided evidence supporting the effectiveness of caregiver preparedness in supporting the acute health care system, particularly in terms of using medical monitoring devices such as sensors to monitor the health indicators of elderly and disabled patients, providing them with service-oriented emergency responses in real time for abnormal health condition cases [11–13].
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Some caregivers reported conflicts about treatment decisions stemming from disagreements about treatment risks or goals or from the implications of treatments for their care provision. Inability to understand the implications of patients’ biomedical conditions is a barrier to caregiver forecasting for elders requiring chronic care [14]. For example, certain complex, commonly underappreciated symptoms and signs among older patients with chronic respiratory disease include voice/speaking problems, urinary incontinence, and worsening confusion. Moreover, medication mismanagement is a growing public health concern, especially among elders. Caregivers often continue to administer and prescribe increasingly frequent medication and/or larger doses, without really judging whether the medications remain effective after long periods of use or other possible interactions [15]. Therefore, the common disease patterns of chronic diseases should be explained to family caregivers, with improved resources to help caregivers anticipate and manage acute care needs [16]. Poorer caregiver outcomes result from inadequate preparations for the caregiving role and collaboration with health professionals for skills training, communication, and resource identification and activation [17]. This study found that informal caregivers in chronic care cases call for more involvement of EMS for improved collaboration in acute health care provision. With regard to collaboration in acute health care, caregivers commonly experience anxiety and uncertainty with concerns over communication, the general environment, delays in symptoms management, and long waiting times for services, although patients and caregivers describe great relief and satisfaction when they finally receive care [18]. Other issues included the negative experiences of caregivers in requesting EMS, including delays, which is a common issue in remote areas in Thailand because of insufficient medical personnel and equipment. Similarly, a study in Namibia found that elderly patients also experienced transport delays, especially in the case of emergencies, and they felt that transport was available, but it was not for their use [19]. Delays in response are natural outcomes when demand outstrips available resources, and health personnel can be delayed at any of the transitional stages from site to hospital because of geographical, traffic, or case-related situations and the complexity of assessing and referring patients [20]. By definition, emergencies can occur at any time in emergency medicine, and new onsets (red flags) such as severe headaches or “worst headache of life” should be evaluated for potential disabling or life-threatening diagnoses. Emergency healthcare providers need to be aware of red flags in patient history and understand examinations that point toward serious underlying causes [21]. If the condition of the patient worsens, caregivers should be able to respond to questions concerning the time of the beginning of clinical changes and/or what characteristics indicated disease progression [22].
Conclusions The findings revealed that family caregivers face serious challenges in managing emergency conditions among dependent older people, including functional decline, and lack of medical equipment and training which affected decision-making processes and resulted in the delay of definitive care provision in many cases. Most participants prefer to call family members for guidance to solve any serious problems during medical emergencies, slowing reactions to sudden deteriorations within the milieu of their experiences and resources. Caregivers viewed the process of healing as complete if the elder felt better or their condition stabilized. However, for dependent elders suffering from deterioration and requiring professional evaluation and treatment, some family caregivers took them to nearby hospitals by private car and others
Please cite this article in press as: Soontorn T, et al. Thai family caregivers’ experiences helping dependent elders during medical emergencies: a qualitative study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.11.002
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requested EMS indirectly by other people such as neighbors or community leaders. There was a notable aversion to utilizing healthcare professional resources in the first instance, and they were generally regarded as the last resort. In addition, response times and the transitional process from the scene to definitive care in hospitals seemed to have barriers in remote areas. Therefore, there is a need in health systems to reform the integration between acute health care and long-team care for dependent elders, which is particularly important in the increasing growth of older people for the aging society. What is already known on this topic Existing research has revealed the significance of developing emergency health care systems in the prehospital phase for dependent older persons. There is little known regarding the experience of caregivers in managing care during medical emergency, particularly in the context of Thailand. What this study adds Most caregivers were able to manage by themselves before calling for emergency assistance. Caregivers reported several barriers when attending dependent older persons with an emergency condition in a rural community. Caregivers require specific skills especially in assessing and recognizing warning signs and initiating first aid appropriately before emergency health care team activation. With an aging society, greater improvement in prehospital services in emergency systems for home- and community-based long-term care is necessary. Provenance and conflicts of interest The authors certify that this study has neither been published in whole nor in part elsewhere, nor is it under consideration elsewhere. The authors also declare that there are no conflicts of interest regarding the publication of this paper. Acknowledgments The authors would like to deeply thank all of the dependent elders and their families who participated in this study. This research project was partially sponsored by the Research and Development Institute, Suratthani Rajabhat University and the Thai Health Promotion Foundation.
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Please cite this article in press as: Soontorn T, et al. Thai family caregivers’ experiences helping dependent elders during medical emergencies: a qualitative study. Australasian Emergency Care (2019), https://doi.org/10.1016/j.auec.2019.11.002