Ethical Issues in Aged Care: I. Information Disclosure II. Informed Consent 1Bioethics June 2012_S. Lo

Ethical Issues in Aged Care:

I. Information Disclosure

II. Informed Consent

1Bioethics June 2012_S. Lo

Bioethics June 2012_S. Lo 2

http://www.census2011.gov.hk/flash/dashboards/population-growth-db-101-en/population-growth-db-101-en.html

Ethical Issues in Aged CareI. Information DisclosureII. Informed Consent


4003002001000100200300400

0 - 45 - 910-1415-19

20-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

Age Group

Thousand Persons

4003002001000100200300400

0 - 45 - 910-1415-19

20-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-84

85+

Age Group

Thousand Persons4003002001000100200300400

0 - 45 - 910-1415-19

20-2425-2930-3435-3940-44

45-4950-5455-5960-64

65-6970-7475-7980-84

85+

Age Group

Thousand Persons

1961 2005 2033

Hong Kong Population Pyramid


Long life expectancy and Ageing population

- Expectation of life at birth :

1983 2005 2033 Male 72.3 78.8 82.5 Female 78.4 84.4 88.0

- Ageing of the population

Population of the elderly (65+) :3.2% (1961) 12.1% (2005) 26.8% (2033)

Outline:


I. Information disclosurea. Right to Information; Autonomyb. Veracity

II. Informed Consent:a. Elder’s mental capacity

b. Information to be givenc. Freedom in decision-making

Ethical Principles:

Beabout & Wennemann, Applied Professional Ethics

Respect for Persons

Non- maleficence

Beneficence

Integrity

Justice

Utility

Double-effect

These are the 3 KEY principles for ethical decision making

These 2 provide checks on consistency

Pragmatic principles that may help resolve specific difficulties.

The fundamental principle – respect an individual's autonomy

Simple but important – do no harm!

When you are certain that you are doing no harm, is there anything positive you can do!

Principle serves as a check on personal consistency.

Principle serves as a check on social consistency.

Principle provides a mechanism for choosing between multiple GOODS.

Principle helps to distinguish the intended GOOD from foreseeable BAD.

A. Right to Information

• Fundamental Human Rights

• Moral doctrine of diagnosis disclosure is derived from: – respect for the elder’s autonomy– beneficence– should truth-telling become a moral

absolute?


I know

something is

wrong with

me, but what

it is?

• Views of carers, patients and their peer• When is it justified to withhold the

truth from an elderly patient?

• Is it justifiable to deceive a patient with a cover-up story?

• What if the truth could be harmful?


B. Veracity

• Professional obligation to tell the truth

• Virtue

• Fidelity (imposes obligations implicitly in a trusting relationship)


C. Informed Consent/Refusal by Elders

10

Voluntariness

Adequate Information

Mental Capacity

Mental Capacity:

All adults are assumed to have capacity, unless they have an impairment affecting their mind (e.g. severe stage of dementia).

The overriding principle is that the disclosure of confidential information is made in the best interests of the person lacking capacity.


Adequate Information

• The diagnosis

• The treatment plan

• Risks of treatment

• Alternatives available

• Opportunity for clarification


Voluntariness

Elders should be able to make

his/her own health care decision

at a free will, not under any

undue influence from the doctor,

family, even the next-of-kin.


Caring and treating elders who lack capacity:

• Paternalism - overriding a person’s known preferences

based on the justification that this will benefit them or avoid harm to them

- easier to justify carrying out life-saving surgery than routine procedures

Hence, paternalism may be justified when applied in the elder’s best interests.


Case 1 for discussion:


Ah Tai, a 68-year-old woman visits her doctor with complaints of abdominal pain that is persistent but

not extreme. Investigation reveals that she has metastatic cancer

of the pancreas. The woman has just retired from a busy professional career, and she and her

husband are about to leave on a round-the-world cruise that they have been planning for over a

year.

Would you tell her her diagnosis? How do you justify your ethical grounds?

Case 2 for discussion:Chan Kueng, an 82-year-old man is

admitted into hospital with a chief concern of weight loss, generalized weakness, and a pulmonary mass

revealed in an x-ray.

His family approaches the doctor and asks that the patient not be told, stating that

in his upbringing in mainland China, tuberculosis (TB) was considered fatal

and to tell him would be like giving him a “death sentence.”


Should the family’s request be complied with? How do you justify your decision?


Mr. Tam is 66 years old and has been brought into hospital with unstable angina. He is clearly worried about why he feels so poorly and what is going ‘to be done’ to him. An angiogram is considered the next useful investigation, but the doctor is concerned that if Mr. Tam is told about the risks he may become very anxious, thus precipitating a fatal myocardial infarction.


To tell or not to tell? How to justify your option with ethical principles?


Leung has schizophrenia and is convinced that worms are crawling over his skin. He finds this extremely distressing.

One treatment that could be tried for him is a new antipsychotic drug, but this carries an 8% risk of permanent eye damage.

Should Leung be informed of this risk? Why?


References:


Casas, A.V., (2008). Patients’ right to information: a review of the regulatory ethical framework. Retrieved on 9 June 2012 from http://www.ub.edu/bid/21/vall3.htm

Hope, T., Savulescu, J. and Hendrick, J. (2003) Medical Ethics and Law: The core curriculum. Churchill Livingstone, Edinburgh.

Pinner, G. (2000). Truth-telling and the diagnosis of dementia. British Journal of Psychiatry. 176, pp. 514-515

Pierce, J. & Randels, G. (2010). Contemporary Bioethics. New York: Oxford University Press.

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Ethical Issues in Aged Care: I. Information Disclosure II. Informed Consent 1Bioethics June 2012_S. Lo