Ethical/Legal Issues in Care of Geriatric Patients
Geriatric Patients in GeneralDo 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
Ethical PrinciplesThe Four Principles
Respect for Persons/Autonomy Acknowledge a persons 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
Respect for Persons/AutonomyProfessionals 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.
JusticeJustice 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
NonmaleficenceThis 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
BeneficenceGood care requires that the health-care provider understand the patient from a holistic perspective that includes the patients beliefs, feelings, and wishes as well as those of the patients 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.
VeracityThe professionals 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.
Different InputsHaving said this, it is sometimes the case that we face different inputs when dealing with geriatric patients
E.g., Different likely outcomes of surgeryGreater 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
Creeping PaternalismA 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
PaternalismGenerally shows up in
Relaxed standards re. confidentiality (with family members)Increased willingness to seek consent from others Increased willingness to treat patient as incompetent
Terms competence and decision-making capacity generally refer to this same issue
Except as defined in legislation, these terms may be used interchangeably
Competence/CapacityCompetence 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.
Approach to competence must be a functional one, determined by a persons 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)
Competence/Capacity - Ethical ImportanceCompetent 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
Competence/Capacity - Legal SignificanceIn 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
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
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 kinlast on list is the health care professional responsible for the proposed health care
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
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
Points to RememberAs long as a person retains decision-making capacity, his or her wishes and decisions shall govern health careA persons 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 herselfCognitive 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.
Age-related changes influence or may impede the process of informed consent for older adults:
Sensory deficits in hearing and visionImpaired ability to ask a questionBoth written and verbal information must be presented appropriately with opportunities to repeat and clarify contentValues and beliefs about making health-care choices (i.e., let the doctor decide)Decision-making capacity that fluctuates or is diminished.
NeglectNot 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
Dealing with NeglectReporting 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
Other IssuesA 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.
Power of AttorneyPower 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 individuals 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.
Mental HealthMental 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