ETHICAL & PRACTICAL ISSUES IN THE ELDERLY

Dr. Angela M. Campbell

Lourdes Medical Association Conference

RCPSG 1st February 2014

WHAT IS GERIATRIC MEDICINE ?

“ Geriatric Medicine is a whole person specialty. Based on a solid infrastructure of general medicine , it involves consideration of psychological , social and spiritual dimensions , together with functional and environmental assessments. A Geriatrician needs to be aware of legal aspects – capacity and consent , human rights , guardianship ; and ethical conundrums , such as when to investigate or treat ”

Prof. G. Mulley : A career in Geriatric Medicine ( BGS Newsletter August 2007 )

THE ELDERLY IN SOCIETY

Demographic changes - the very elderly, over 85s , are the fastest growing section of society

Health economic implications – increasing need and cost of health and social care for the frail elderly population

Changing role of the elderly in society – contribution and quality of life

PRINCIPLES OF MEDICAL ETHICS

Autonomy – authentic “ self-determination ” influenced by information given , cognition , mood , and personal versus societal values Justice – “ fair ” allocation of health and social care resources based on need and without discrimination Beneficence – “ do good ”Non-maleficence – “ do no harm ”

ETHICAL CHALLENGES IN GERIATRIC MEDICINE

Witholding and withdrawing treatment e.g. enteral nutrition , CPR

Consent and mental capacity

Advanced directives

Euthanasia ( “ a good death ” )

WHAT IS MENTAL CAPACITY ?

An adult is “ capable ” if he or she has :

Received information to make a decision

Is not under pressure from someone else

Can communicate the decision

Consistently holds to this decision

WHAT IS MENTAL INCAPACITY ?

An adult is “ incapable ”if he or she :

Cannot act or make decisions or communicate decisions or understand decisions or retain memory of the decision - because of mental disorder or inability to communicate

Not all or none

May be capable of certain types of decisions but not others

AWISA ( 2000 ) & MENTAL CAPACITY ACT ( 2005 ) - GENERAL PRINCIPLES

Benefit the adult

Take account of adult`s past and present wishes

Take account of views of relevant others

Use the least restrictive power possible

Adult must be encouraged to use existing skills

AREAS COVERED

Decisions about a) money and property b) health and welfare c) both

Intervention order - covers single issue e.g. property sale

Guardianship order - covers long-term needs e.g. in dementia

GUARDIANSHIP

2 doctors` reports confirming incapacity

Mental Health Officer report ( if welfare )

Relevant adult ( if financial only )

Granted by a sheriff and registered by the Public Guardian

Usually for 3 years but may be indefinite

CURRENT USE

Many elderly in institutional care are incapable – certificate and treatment plan reviewed annually ( now every 3 years if established incapacity )

Emergency treatment exempt but must consult proxy for other interventions e.g. elective surgery , enteral nutrition , antibiotics

Proxy decision makers may be formal welfare guardian or informal e.g. NOK

GUIDANCE ON ETHICAL ISSUESHippocratic Oath e.g. “ no intentional killing by act or omission ”

Professional bodies e.g. BMA, GMC , BGS

“ Decisions relating to cardiopulmonary resuscitation : a joint statement ” BMA , Resuscitation Council ( UK ) , RCN ( 2007 )

“ Treatment and care towards the end of life : good practice in decision making ” GMC ( 2010 )

Theological guidance e.g. CTS 2010

GMC GUIDANCE : END OF LIFE CARE

“ Good end of life care helps patients with life-limiting conditions to live as well as possible until they die , and to die with dignity ”

End of life conditions – progressive conditions , organ or systems failure , acute catastrophic events , PVS

Most difficult decisions are often around starting or stopping potentially life-prolonging treatments – benefit versus burden of care

GMC GUIDANCE : ETHICAL PRINCIPLES

Based on Human Rights Act ( 1998 )Presumption in favour of prolonging lifeOffer treatments where possible benefits outweigh any burdens or risksAvoid treatments which will not work , provide no overall benefit or have been refused by a competent patientIf patient incompetent must consult Welfare POA / Guardian / Advocate , healthcare team and take into account e.g. advance directive

GMC GUIDANCE : CLINICAL JUDGEMENT

Refer to relevant clinical guidelines for specific conditionsSeek opinion of relevant specialistCommunicate effectively with patient or relevant others to ensure realistic understanding of expected outcome and benefits , burdens and risks of interventionsIf patient incompetent and there is uncertainty about overall benefit treatment should be started , reviewed and later stopped if ineffective or too burdensomeEthically witholding and withdrawing treatment are the same but the latter is often emotionally more difficult – this should not affect clinical judgementResource constraints may be an issue

GMC GUIDANCE :CLINICALLYASSISTED NUTRITION & HYDRATION ( 1 )

Need to assess patient`s nutritional and hydration status and ensure that this is optimised where possible via the oral routeIn patients unable to maintain adequate nutrition and hydration status orally options include IV or S/C fluids , NG , or RIG / PEG feeding“ The current evidence about the benefits and burdens of these techniques in treating and managing patients towards the end of life is not clear cut ”

ENTERAL FEEDING

ACUTE STROKE

Dysphagia common but usually resolves within a month

Severe stroke and persistent dysphagia has high mortality

PEG / RIG superior to NG

DEMENTIA

Dysphagia versus food refusal

Mortality at 1 year 87% ( in stroke 56% )

Meta-analysis showed no significant benefit

GMC GUIDANCE : CLINICALLY-ASSISTED

NUTRITION & HYDRATION ( 2 ) If these might prolong a patient`s life then treatment should be offered“ Where a patient`s death is not imminent but their condition is severe and the prognosis very poor you may consider that clinically-assisted nutrition and hydration , while likely to prolong their life , will cause them suffering which could be intolerable ”“ You must seek a second or expert opinion from a senior clinician……..You should also consider seeking legal advice ”

EUTHANASIA “ A GOOD DEATH ”

Killing is murder and assisting suicide a criminal offence

A competent patient can refuse treatment

Treatment of an incompetent patient should be in their best interest.This may be by witholding burdensome treatment or providing palliative treatment that could shorten life – “ doctrine of double effect ”

“ Burden ” of care versus sanctity of life

“ Slippery slope ” - a right to die or a duty to die ?

LIVERPOOL CARE PATHWAY

LIVERPOOL CARE PATHWAY

ICP designed to manage the care of a person in the last days or hours of life - facilitates MDT communication / documentation

Criteria for use – possible reversible causes for current condition have been considered ; MDT agreed that patient is dying ; 2 of following apply : bedbound , semi-comatose , unable to take sips of fluid , no longer able to take tablets

LCP – ANTICIPATORY PRESCRIBING

Pain – Morphine

Nausea – Levomepromazine

Agitation – Midazolam

Excess respiratory secretions – Hyoscine butylbromide

LCP - CONTROVERSY

Care or neglect ?

“ Pathway to death ”

Hospice vs acute hospital setting

Diagnosis of “ dying ”

Ethical principles

Training & audit

10 KEY LCP MESSAGES LCP is only as good as those who use it

LCP should not be used without education & training

Good communication is pivotal to success

LCP neither hastens nor postpones death

Diagnosis of dying should be made by the MDT

LCP does not recommend use of deep continuous sedation

LCP does not preclude “ artificial ” hydration

LCP supports continual reassessment

Reflect , audit , measure & learn

Stop , think , assess , change

NEUBERGER REPORT ON THE LCP “ MORE CARE LESS PATHWAY ” JULY 2013

Nutrition & hydration in the last days and hours of life

Recognising the uncertainty of the diagnosis of dying

Communication with patients and families and between staff

INTERIM GUIDANCE :CARING FOR PEOPLE IN THE LAST DAYS & HOURS OF LIFE ( KEY PRINCIPLES )

NHS SCOTLAND DECEMBER 2013

Communication

MDT discussion and decision making

Address physical , psychological , social and spiritual needs

Consider needs of relatives and carers

ISSUES ON PILGRIMAGE TO LOURDES

Elderly – assess co-morbidities , function and cognition , capacity , polypharmacy and medication administration

Management of symptoms – prior to travel on pilgrimage seek advice / care plan from local Palliative care team

Consider and discuss potential impact of journey and pilgrimage on symptoms

Clarify insight of pilgrim and their relatives on prognosis and establish if there is an ACP

Insurance cover - implications of change / deterioration in condition and of hospitalisation in France