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Living a little more dangerously
THE LANCET
Living a little more dangerously C Patterson, C Rosenthal
Courtesy of the National Portrait Gallery, London.
Factors which determine perception of risk are How do old people view risk? Would most wish to enjoy complex.3 While conceptually we can divide individuals life more, or perhaps for fewer years? Consider the into risk-averse, normal, and risk-taking (table), following. perception and behaviour for different activities may Mrs G has always enjoyed eating. She is now 80 and in differ substantially. good health. At her son’s Smokers may be more suggestion she asks her Portraits of ageing—3 concerned about the physician to measure her health effects of food serum cholesterol. It is additives than about the high (6·8 mmol/L) and dangers of tobacco, she is placed on a and heavy smokers reduced energy and acknowledge less health reduced saturated fat risk than light smokers diet. In six months she do.4 People will accept loses 14 kg in weight and voluntary risks (eg, feels miserable. skiing) that may be 1000 78-year-old Mr F has times greater than always been fiercely involuntary hazards such independent. When he as food preservatives.3 was admitted to hospital Risks perceived by with pneumonia it was individuals often differ clear that he lacked substantially from the insight into personal perceptions of “experts”. safety. Some members of For example, American the geriatric team felt he women voters and should not go home college students both because he was at too ranked nuclear power great a risk (a smoker, as the highest risk of unreliable with his 30 activities and medications, socially technologies; experts isolated, and with a flight ranked motor vehicles of stairs to his first and nuclear power bathroom). However, Mr as 20th.3 Some evidence F says he will die if he suggests that we become cannot go home. These more risk-averse as we two scenarios bring into Joseph Conrad (1857-1924 ) by Walter Tittle, 1923-24 grow older and that focus the issue of risk, The writer Joseph Conrad is shown here without the usual inflexible individuals with which all physicians props of desk, pen, and paper. In Tittle's portrait (oil on may take greater risks. are familiar but most are canvas, 85·1 ⫻ 69·9 cm), there is an air of the old sea Psychometric tools used pitifully inadequate at captain, and the heavy-lidded eyes, strong nose, and to assess perception of assessing in the context distinguished beard, together with the background of sea and risk give inconsistent of the individual sky, evoke some of the essence of Conrad's writing. Nonetheless, results.5 allegedly at risk. estimating the Much has been written magnitude of risk is essential. Depriving a well 80-yearabout the tension between autonomy (the right of selfold woman of a diet she enjoys is unlikely to prolong life government or personal freedom) and paternalism and is certain to diminish its quality. There is no (limiting freedom and responsibility by well-meant scientific or moral dilemma here; she should be left to regulations). A sense of control over our lives is important enjoy her food. There is increasing interest in to all of us. Older people who make choices about events “enjoyment” as a tool for health promotion. A recent in their lives are less stressed and enjoy better health.1 international workshop explored whether pleasurable Physicians fully understand these issues yet we struggle in activities can improve health, providing the guilt of daily practice to respect that autonomy and to control the indulgence can be overcome.6 Seeking a balance between paternalism engendered by medical practice.2 risk and pleasure makes sense in terms of a patient’s quality of life. Lancet 1997; 350: 1164–65 Attempts have been made to classify “risky discharges” Division of Geriatric Medicine, McMaster University, Hamilton, of older people from hospital.7 Medical factors that Ontario, L8N 3Z5, Canada (Prof C Patterson MD); and Office of prompt concern are, for example, confusion (especially Gerontological Studies, McMaster University, Hamilton, Ontario (Prof C Rosenthal PhD) when fluctuating), non-compliance with treatment, depression, and unstable medical conditions; mobility Correspondence to: Prof C Patterson 1164
Vol 350 • October 18, 1997
THE LANCET
Approach to estimating risk Many contributions are possible: illustrated are the worst and best scenarios and a purely intermediate one.
issues include repeated falling, unsteadiness, and using furniture to steady gait; and personality factors apply to those who are non-cooperative, say (but not demented), who refuse advice, or who are too independent. Assessing the magnitude of these risks in individuals is very difficult and tends to be subjective. Serious harm may be suspected for someone living at home who fits the acronym RISK, where R=roaming or wandering (eg, in traffic or inappropriately clothed); I=imminent physical danger (eg, burning cooking utensils, falling and unable to summon help); S=suicide; K=kin (ie, risk to relatives or caregivers through violent or aggressive behaviour). Mr F’s choice to go home and maintain his sense of control may outweigh all but the most serious hazards posed by his discharge.8 A major concern with old people is the loss of insight that may occur with frontal lobe dysfunction and other conditions. The prevalence of dementing illnesses rises sharply with age: loss of insight is common in Alzheimer’s and other dementias and is a prominent feature of frontal lobe dementias. The ability of healthcare professionals to decide if someone lacks insight into risk will depend upon their experience, cultural biases, and fear of litigation. Distinguishing poor insight and judgment from stoicism or even courage can be most difficult. The availability of support has a major effect on professionals’ assessment of risk. A patient who falls repeatedly or cannot adhere to a medication regimen can have these handicaps alleviated by the presence of a caregiver. For this reason, those of lower socioeconomic status, who may not have access to formal caregivers, are usually regarded as being at higher risk. Experts often disagree with their patients about the degree of risk and such disagreements should not be expected to evaporate in the presence of evidence. When evidence is consistent with previously held views, it is
Vol 350 • October 18, 1997
accepted; if not, it is often dismissed.3 The individual old person and the “experts” often come into conflict about the following: living alone at risk (or having that risk alleviated by residing in an institution); following advice on health promotion; choosing to ignore a recommendation for a pureed diet to reduce the risk of aspiration pneumonia; choosing not to have a radical (and curative) procedure for cancer for fear of disabling consequences; determining how much money to put away for retirement; restricting activity in individuals who fall; and motor vehicle driving. Perception of risk is highly individual. It involves the personality of the individual, the magnitude of the perceived risk, and the means by which that risk can be overcome. Because physicians think that “we know better”, we run the risk of being paternalistic to older patients who choose a course other than the one we recommend. Older people benefit from the sense of control that making decisions gives them. Many are prepared to take risks which may balance quality against duration of life, and duration of life may be less important to patients than clinicians believe. Only 5% of seniors in one study were worried about dying or short life expectancy.9 Clinicians, trained to treat disease, are often reluctant to support such decisions but we must not impose our own values and instead come to understand better what is important to our patients and how their decisions can be supported, unless they are truly incapable. We thank Dr Peteris Darzins for discussion of some of the ideas in this article.
References 1 2
3 4 5 6
7
8 9
Rodin J. Aging and health: effects of the sense of control. Science 1986; 233: 1271–76. Kaufman SR. Old age, disease, and the discourse on risk: geriatric assessment in the US health care. Med Anthropol Q 1994; 8: 430–37. Slovic P. Perception of risk. Science 1987; 236: 280–85. Lave LB. Health and safety risk analyses: information for better decisions. Science 1987; 236: 291–95. Lupton D. Risk as moral danger: the social and political functions of risk discourse in public health. Int J Health Services 1993; 23: 425–35. Association for Research into the Science of Enjoyment. Workshop on the Value of Pleasures and the Question of Guilt (Rome, April 20–23, 1997). Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nursing 1994; 29: 249–56. Tierney MC. How safe are cognitively impaired seniors who live alone. Can J Aging 1997; 16: 177–89. Connidis I. Life in older age: the view from the top. In: Marshall VW, ed. Aging in Canada: social perspectives, 2nd ed. Markham, Ontario: Fitzhenry & Whiteside, 1987: 451–72.
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Living a little more dangerously C Patterson, C Rosenthal
Courtesy of the National Portrait Gallery, London.
Factors which determine perception of risk are How do old people view risk? Would most wish to enjoy complex.3 While conceptually we can divide individuals life more, or perhaps for fewer years? Consider the into risk-averse, normal, and risk-taking (table), following. perception and behaviour for different activities may Mrs G has always enjoyed eating. She is now 80 and in differ substantially. good health. At her son’s Smokers may be more suggestion she asks her Portraits of ageing—3 concerned about the physician to measure her health effects of food serum cholesterol. It is additives than about the high (6·8 mmol/L) and dangers of tobacco, she is placed on a and heavy smokers reduced energy and acknowledge less health reduced saturated fat risk than light smokers diet. In six months she do.4 People will accept loses 14 kg in weight and voluntary risks (eg, feels miserable. skiing) that may be 1000 78-year-old Mr F has times greater than always been fiercely involuntary hazards such independent. When he as food preservatives.3 was admitted to hospital Risks perceived by with pneumonia it was individuals often differ clear that he lacked substantially from the insight into personal perceptions of “experts”. safety. Some members of For example, American the geriatric team felt he women voters and should not go home college students both because he was at too ranked nuclear power great a risk (a smoker, as the highest risk of unreliable with his 30 activities and medications, socially technologies; experts isolated, and with a flight ranked motor vehicles of stairs to his first and nuclear power bathroom). However, Mr as 20th.3 Some evidence F says he will die if he suggests that we become cannot go home. These more risk-averse as we two scenarios bring into Joseph Conrad (1857-1924 ) by Walter Tittle, 1923-24 grow older and that focus the issue of risk, The writer Joseph Conrad is shown here without the usual inflexible individuals with which all physicians props of desk, pen, and paper. In Tittle's portrait (oil on may take greater risks. are familiar but most are canvas, 85·1 ⫻ 69·9 cm), there is an air of the old sea Psychometric tools used pitifully inadequate at captain, and the heavy-lidded eyes, strong nose, and to assess perception of assessing in the context distinguished beard, together with the background of sea and risk give inconsistent of the individual sky, evoke some of the essence of Conrad's writing. Nonetheless, results.5 allegedly at risk. estimating the Much has been written magnitude of risk is essential. Depriving a well 80-yearabout the tension between autonomy (the right of selfold woman of a diet she enjoys is unlikely to prolong life government or personal freedom) and paternalism and is certain to diminish its quality. There is no (limiting freedom and responsibility by well-meant scientific or moral dilemma here; she should be left to regulations). A sense of control over our lives is important enjoy her food. There is increasing interest in to all of us. Older people who make choices about events “enjoyment” as a tool for health promotion. A recent in their lives are less stressed and enjoy better health.1 international workshop explored whether pleasurable Physicians fully understand these issues yet we struggle in activities can improve health, providing the guilt of daily practice to respect that autonomy and to control the indulgence can be overcome.6 Seeking a balance between paternalism engendered by medical practice.2 risk and pleasure makes sense in terms of a patient’s quality of life. Lancet 1997; 350: 1164–65 Attempts have been made to classify “risky discharges” Division of Geriatric Medicine, McMaster University, Hamilton, of older people from hospital.7 Medical factors that Ontario, L8N 3Z5, Canada (Prof C Patterson MD); and Office of prompt concern are, for example, confusion (especially Gerontological Studies, McMaster University, Hamilton, Ontario (Prof C Rosenthal PhD) when fluctuating), non-compliance with treatment, depression, and unstable medical conditions; mobility Correspondence to: Prof C Patterson 1164
Vol 350 • October 18, 1997
THE LANCET
Approach to estimating risk Many contributions are possible: illustrated are the worst and best scenarios and a purely intermediate one.
issues include repeated falling, unsteadiness, and using furniture to steady gait; and personality factors apply to those who are non-cooperative, say (but not demented), who refuse advice, or who are too independent. Assessing the magnitude of these risks in individuals is very difficult and tends to be subjective. Serious harm may be suspected for someone living at home who fits the acronym RISK, where R=roaming or wandering (eg, in traffic or inappropriately clothed); I=imminent physical danger (eg, burning cooking utensils, falling and unable to summon help); S=suicide; K=kin (ie, risk to relatives or caregivers through violent or aggressive behaviour). Mr F’s choice to go home and maintain his sense of control may outweigh all but the most serious hazards posed by his discharge.8 A major concern with old people is the loss of insight that may occur with frontal lobe dysfunction and other conditions. The prevalence of dementing illnesses rises sharply with age: loss of insight is common in Alzheimer’s and other dementias and is a prominent feature of frontal lobe dementias. The ability of healthcare professionals to decide if someone lacks insight into risk will depend upon their experience, cultural biases, and fear of litigation. Distinguishing poor insight and judgment from stoicism or even courage can be most difficult. The availability of support has a major effect on professionals’ assessment of risk. A patient who falls repeatedly or cannot adhere to a medication regimen can have these handicaps alleviated by the presence of a caregiver. For this reason, those of lower socioeconomic status, who may not have access to formal caregivers, are usually regarded as being at higher risk. Experts often disagree with their patients about the degree of risk and such disagreements should not be expected to evaporate in the presence of evidence. When evidence is consistent with previously held views, it is
Vol 350 • October 18, 1997
accepted; if not, it is often dismissed.3 The individual old person and the “experts” often come into conflict about the following: living alone at risk (or having that risk alleviated by residing in an institution); following advice on health promotion; choosing to ignore a recommendation for a pureed diet to reduce the risk of aspiration pneumonia; choosing not to have a radical (and curative) procedure for cancer for fear of disabling consequences; determining how much money to put away for retirement; restricting activity in individuals who fall; and motor vehicle driving. Perception of risk is highly individual. It involves the personality of the individual, the magnitude of the perceived risk, and the means by which that risk can be overcome. Because physicians think that “we know better”, we run the risk of being paternalistic to older patients who choose a course other than the one we recommend. Older people benefit from the sense of control that making decisions gives them. Many are prepared to take risks which may balance quality against duration of life, and duration of life may be less important to patients than clinicians believe. Only 5% of seniors in one study were worried about dying or short life expectancy.9 Clinicians, trained to treat disease, are often reluctant to support such decisions but we must not impose our own values and instead come to understand better what is important to our patients and how their decisions can be supported, unless they are truly incapable. We thank Dr Peteris Darzins for discussion of some of the ideas in this article.
References 1 2
3 4 5 6
7
8 9
Rodin J. Aging and health: effects of the sense of control. Science 1986; 233: 1271–76. Kaufman SR. Old age, disease, and the discourse on risk: geriatric assessment in the US health care. Med Anthropol Q 1994; 8: 430–37. Slovic P. Perception of risk. Science 1987; 236: 280–85. Lave LB. Health and safety risk analyses: information for better decisions. Science 1987; 236: 291–95. Lupton D. Risk as moral danger: the social and political functions of risk discourse in public health. Int J Health Services 1993; 23: 425–35. Association for Research into the Science of Enjoyment. Workshop on the Value of Pleasures and the Question of Guilt (Rome, April 20–23, 1997). Macmillan MS. Hospital staff’s perceptions of risk associated with the discharge of elderly people from acute hospital care. J Adv Nursing 1994; 29: 249–56. Tierney MC. How safe are cognitively impaired seniors who live alone. Can J Aging 1997; 16: 177–89. Connidis I. Life in older age: the view from the top. In: Marshall VW, ed. Aging in Canada: social perspectives, 2nd ed. Markham, Ontario: Fitzhenry & Whiteside, 1987: 451–72.
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