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Ethical/Legal Issues in Care of Geriatric Patients

Ethical Legal Issues

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Page 2: Ethical Legal Issues

Geriatric Patients in General Do distinct issues arise when caring for the

elderly?

– Issues such as informed consent

E.g. patients with Alzheimer's

– Can generalities about geriatric patients be easily drawn ?

Are all 90 year olds senile

Page 3: Ethical Legal Issues

Ethical Principles

The ‘Four Principles’

– Autonomy/Respect– Beneficence– Non-maleficence– Justice

Page 4: Ethical Legal Issues

Respect for Persons/Autonomy

Acknowledge a person’s right to make choices, to hold views, and to take actions based on personal values and beliefs

Justice Treat others equitably.

Nonmaleficence (do no harm)

Obligation not to inflict harm intentionally;

Beneficence (do good)

Provide benefits to persons and contribute to their welfare. Refers to an action done for the benefit of others.

Veracity To be honest and trustworthy in their dealings with people

Page 5: Ethical Legal Issues

Respect for Persons/Autonomy Professionals have a duty to treat the patient according to the

patient's desires, within the bounds of accepted treatment, and to protect the patient's confidentiality

Primary obligations include involving the patient in treatment decisions in a meaningful way, with due consideration being given to the patient's needs, desires and abilities, and safeguarding the patient's privacy

Nurses may interfere only when they believe a person does not have sufficient information or capacity to understand, or is being coerced.

Page 6: Ethical Legal Issues

Justice

Justice is the least discussed principle, but relevant here.

– ‘like cases should be treated alike’ – chronological age alone should never be a consideration in whether a particular treatment is recommended

Page 7: Ethical Legal Issues

Nonmaleficence This principle expresses the concept

that professionals have a duty to protect the patient from harm.

This principle requires that health-care providers protect those patients from harm if they cannot protect themselves

Page 8: Ethical Legal Issues

Beneficence Good care requires that the health-care provider

understand the patient from a holistic perspective that includes the patient’s beliefs, feelings, and wishes as well as those of the patient’s family and significant others

Beneficence is the motivating force behind caring; however, beneficence is complex because it is difficult to determine what exactly is good for another and who can make the decisions about what is good.

Page 9: Ethical Legal Issues

Veracity The professional’s primary obligations include

respecting the position of trust inherent in the physician-patient, nurse-patient, and other healthcare provider-patient relationships, communicating truthfully and without deception, and maintaining intellectual integrity.

Veracity or truthfulness requires that health-care providers not intentionally deceive or mislead patients.

Page 10: Ethical Legal Issues

Different ‘Inputs’ Having said this, it is sometimes the case that we face

different ‘inputs’ when dealing with geriatric patients

– E.g., Different likely outcomes of surgery– Greater focus on pain relief

When this is true, it is clearly of ethical relevance, however we should be very careful about assuming this is true in a particular case

– E.g., “Would you give the transplant to the 70 year old or the 20 year old?” – Too simple

Page 11: Ethical Legal Issues

‘Creeping Paternalism’

A central issue in dealing with geriatric patients is what we might call ‘creeping paternalism’

– ‘Creeping’ because it sometimes operates unsaid

Tendency to assume that geriatric patients are not fully capable of making their own decisions

Page 12: Ethical Legal Issues

Paternalism

Generally shows up in

– Relaxed standards re. confidentiality (with family members)

– Increased willingness to seek consent from others

– Increased willingness to treat patient as incompetent

Page 13: Ethical Legal Issues

Competence/Capacity

Terms “competence” and decision-making “capacity” generally refer to this same issue

Except as defined in legislation, these terms may be used interchangeably

Page 14: Ethical Legal Issues

Competence/Capacity Competence has tended in the past to be

considered in an “all-or-none” sense:

i.e., the idea of a person being “declared incompetent” and losing rights re finances, property, voting, health care decisions, etc.

Page 15: Ethical Legal Issues

Competence/Capacity

Approach to competence must be a functional one, determined by a person’s ability to understand, retain and assess information in order to make a choice and then communicate that choice

In the health care context, it is the ability to understand information relevant to a health care decision and to appreciate the reasonably foreseeable consequences of a decision (or lack of decision)

Page 16: Ethical Legal Issues

Competence/Capacity - Ethical Importance Competent patients are, by definition, able to give

informed consent to treatment

The importance of informed consent is supported both by

– the principle of autonomy - respect for persons requires respecting their informed decisions

– the principles of beneficence/non-maleficence - generally, an informed patient is a good judge of what broad sort of treatment is in his/her best interest

Page 17: Ethical Legal Issues

Competence/Capacity - Legal Significance In law, competent patients are entitled to

make their own informed decisions

If a patient is incapable, physician must obtain consent from a substitute decision maker

Page 18: Ethical Legal Issues

Choosing Substitute Decision Maker (SDM)

Where a health care professional has patient who requires health care but lacks competency to make health care decision; must make reasonable attempt to determine whether patient has substitute decision maker who is available

Emergency exception - consent not required where health care necessary to preserve life or health and delay in finding SDM may pose significant risk to patient

Page 19: Ethical Legal Issues

Choosing Substitute Decision Maker (SDM) Hierarchical list of substitute decision-makers if one

not appointed, or appointed person is unable/unwilling to act

– next of kin– last on list is the health care professional

responsible for the proposed health care

Page 20: Ethical Legal Issues

Choosing Substitute Decision Maker (SDM)

SDM must act in accordance with:

(a) directions of the health care provider(b) the wishes of the patient as expressed to SDM when

competent; or(c) what the SDM believes to be the best interests of

patient

SDM entitled to information necessary to make informed decision

Page 21: Ethical Legal Issues

Choosing Substitute Decision Maker (SDM) Where doctor determines patient not

competent to make health care decision:

– must document it in chart and – Ensure SDM is aware of right to contest

finding – protection from liability for health care

professional and SDM if acting in good faith

Page 22: Ethical Legal Issues

Points to Remember As long as a person retains decision-making capacity,

his or her wishes and decisions shall govern health care

A person’s capacity to make health-care decisions is usually self-evident. On the other hand, in advanced old age, and in the face of dementia, it is often unclear as to whether a person is capable of making specific health-care decisions for him- or herself

Cognitive impairment does not automatically constitute incapacity. For example an older adult may be declared incompetent in one domain such as in handling financial matters, but may retain the ability to make medical decisions.

Page 23: Ethical Legal Issues

Age-related changes influence or may impede the process of informed consent for older adults:

Sensory deficits in hearing and vision

Impaired ability to ask a question

Both written and verbal information must be

presented appropriately with opportunities to repeat

and clarify content

Values and beliefs about making health-care choices

(i.e., “let the doctor decide”)

Decision-making capacity that fluctuates or is

diminished.

Page 24: Ethical Legal Issues

Neglect Not commonly used piece of legislation

Definition “neglected adult”

– incapable of caring properly for him/herself because of physical or mental infirmity,

– not receiving proper care and attention, – refuses, delays or is unable to make provision for

proper care for self, and – is not suitable for treatment under Mental Health

Act

Page 25: Ethical Legal Issues

Dealing with Neglect

Reporting to social worker or Director who conducts an investigation

Application to judge for declaration of “neglected adult”

If finding made, judge may direct placement of individual

Page 26: Ethical Legal Issues

Other Issues

A Living Will provides specific instructions about the particular kinds of treatments / interventions an individual would or would not want to prolong or sustain life.

Living Wills are generally used to declare wishes, to refuse, limit, or to withhold life sustaining treatment under certain circumstances should the individual lose capacity and become unable to communicate.

Page 27: Ethical Legal Issues

Power of Attorney Power of Attorney - an individual designated, and

who is presumably known and trusted by the patient, to make health-care decisions for them should they lose decision-making capacity.

The agent or surrogate can interpret the individual’s wishes as medical circumstances change.

A surrogate, one who makes decisions on behalf of another who is unable to make decisions for him- or herself, can be designated either informally or formally.

Page 28: Ethical Legal Issues

Mental Health

Mental Health Act

– deals with involuntary detention and treatment of persons with mental disorders (disease or disability of the mind) who require hospitalization in the interests of their own safety, safety of others (or safety to property)

– certificates signed by physicians

Page 29: Ethical Legal Issues

Questions