1. Ethical Issues In Geriatric Care Dr. DOHA RASHEEDY ALY Lecturer of Geriatric Medicine Department of Geriatric and Gerontology Ain Shams University
2. Introduction: The competent practice of geriatric medicine requires physicians and other clinicians to master both a body of knowledge about how to diagnose and treat geriatric health conditions and an ethic to apply this knowledge to the care of their patients. the ethics of patient care focus on using the principles of respect for autonomy and beneficence.
3. Introduction: Medical practice occurs within a legal and regulatory context. it is critical for clinicians to be familiar with the specific requirements and standards in the jurisdictions in which they practice. As a general rule, it is most important that physicians recognize that the best way to avoid legal problems is to be aware of legal requirements in the jurisdictions in which they practice, but to think clinically and not legally in the provision of consistent and sound clinical care to their patients
4. CONFIDENTIALITY ANDMANDATORY REPORTING LAWS
5. CONFIDENTIALITY ANDMANDATORY REPORTING LAWS As early as 430 BC, confidentiality was codified in the Hippocratic Oath, “Whatever I see or hear, professionally or privately, which ought not to be divulged, I will keep secret and tell no one. The principle of confidentiality remains an important ethical, legal, and professional practice in clinical medicine. The absolute confidentiality of the Hippocratic Oath, however, has given way to several exceptions that reflect a complex balance between the importance of privacy as a necessary component of the doctor- patient relationship that respects patient autonomy and facilitates honest information-sharing for treatment on the one hand, and the many demands of an ever more complex society on the other. Specifically, courts and legislatures have determined that certain concerns, such as public safety, justify modification of absolute confidentiality.
6. Examples of situations in which public policy considerations limit doctor-patient confidentiality include mandated reporting of infectious diseases and suspected child and elder abuse. States and the federal government have regulations that govern which communicable diseases should be reported to local and state authorities and/or the Centers for Disease Control and Prevention (CDC); this list is revised annually. all states require reporting of internationally quarantinable diseases (including cholera, plague, and yellow fever) An additional exceptions to confidentiality for public safety and welfare considerations. One such area includes the duty to warn or protect third parties from, threatened physical harm from
7. • a 42-year-old man is hospitalized with chest pain. The patient is• awake and alert. His wife comes to you demanding information about the patient, saying that she is his wife. She shows her identification card verifying this. What should you tell her?
8. • you receive a phone call from another physician who is well known to you in your local community. The physician says that one of your former patients has transferred his care to him and he is asking for a copy of the patient$ medical record. What do you tell him?
9. Diagnostic disclosure
10. Diagnostic disclosure On the side for disclosure is the argument that patients deserve the truth and to deny this information to them is to deny an adult’s right to the truth. The argument against disclosure is that not all truth is good to tell, especially to a person who may be harmed by it. In ethical terms, these competing arguments square off as a dilemma between respecting the principles of autonomy versus beneficence. In short, is it better to be honest but risk cruelty. Diagnostic disclosure depends on the capacity of the persons to understand and appreciate the diagnosis, their expressed desire to know what is wrong, and the emotional and moral impacts that this knowledge may have. Decisions concerning disclosure should also account for the role of the caregivers and the power they hold over the patients.One critical step in living with an illness is to understand andappreciate it. Understanding is about knowing the facts. In the case of a person with a chronic illness, it means knowing what the illness is, what stage the patient is at, what to expect in the future, and what can be done to maximize quality of life. In contrast, appreciation describes how well a person recognizes how facts apply to him- or herself. This ability is distinct from
11. In the case of persons with Alzheimer’s disease, several studies have shown that many persons with mild-stage Alzheimer’s disease can understand information. Although they may not remember it, when taught, they are often able to provide a relatively accurate restatement of the facts when asked to summarize what they have learned. Appreciation is a complex issue in persons with Alzheimer’s disease. It is often mixed. A patient may appreciate one feature of the disease, but not another. In the case of appreciating Alzheimer’s disease, there are at least three features: the diagnosis, the severity, and the prognosis. Studies examining appreciation show that patients may appreciate one of these features but not the other. That is, patients may be aware of their diagnosis, but not the severity and prognosis.
12. Steps to Disclose a Diagnosis of Alzheimer’s Disease Step 1. Assess patients’ awareness of their cognitive problems. Step 2. Assess the degree to which patients are bothered by these problems. Step 3. Assess patients’ desire to know the cause of their memory problems. Step 4. Assess patients’ understanding of Alzheimer’s disease and their desire to know if they have that disease.
13. Diagnostic Disclosure You should arrange a joint meeting with the individual and the family members to disclose the diagnosis. Telling families the diagnosis is Alzheimer’s can be difficult, since there is currently no promising prognosis for those affected. Because the initial meeting can be overwhelming, you may need to schedule a follow-up meeting to continue discussion of the diagnosis and available support services. After disclosing the diagnosis, expect various responses from the individual and family, ranging from acceptance of what was suspected and relief at learning what is causing behavioral
14. Disclosing the diagnosis Consider the following before communicating the diagnosis: Gain an understanding of family dynamics and cultural values. When possible, include all of the professionals (nurses, social workers, psychologists and others ) involved in determining the diagnosis in the joint meeting to answer questions and provide specific recommendations. Allow sufficient time to answer questions from the individual and family. A follow-up meeting may need to be scheduled to continue discussion. Discuss how the disease might progress and agree upon a specific care plan that considers the person’s values and beliefs.
15. Covering key issues Alzheimer’s disease is not a normal part of aging, but a degenerative disease of the brain that results in impaired memory, thinking and behavior. Alzheimer’s disease affects every individual differently, so there is no exact way to determine how the disease will progress. While there is no cure for the disease, some of its symptoms can be treated by medications and behavioral approaches. Disclosure of the diagnosis allows the individual to maximize quality of life and be involved in planning future care decisions. Assistance is available from the Alzheimer’s Association and other resources. Progress is being made in research. One way to help that progress is by participating in clinical drug studies. To locate the clinical drug studies being conducted in the Throughout the diagnostic evaluation and treatment planning, you should involve the family and caregiver. As the disease progresses and patients become increasingly dependent on their caregivers, these individuals will become your primary source of information on the patient’s daily mental and physical health. Finally, bear in mind that the primary caregiver and other
16. •Andrew who is a retired engineer lives with his wife Joan who suffered from memory lapses for several years. They have an outpatient clinic appointment in hospital for assessment of her memory problems. •Joan was assessed by the doctor and asked to wait in another room. John who was outside in the waiting area was called in all by himself and the news that his wife has Alzheimer’s disease was broken to him and the symptoms were confirmed.• Andrew was in the room with 3 strangers who sat looking at him waiting for his reaction. He was asked whether his wife Joan should be informed of her diagnosis. Andrew asked for advice from the doctor who informed him that it was ultimately his decision. Andrew decided to call Joan in the clinic room as he thought that Joan was a mature lady and would understand and adapt to the situation.• Andrew felt he could perhaps help her realize that she did have a progressive memory problem. she was informed of the diagnosis and she sat motionless, disbelieving in the diagnosis. •For a while after the diagnosis was disclosed Joan was calm. She however had frequent appointments in the memory clinic with further tests due to which she began to rebel. Andrew helped her to go to a local day center which worked for a while after which she refused to go. •Joan started developing verbally aggressive behavior towards Andrew and he bore the brunt of it. He was hence put in touch with the admiral nurse service for carer distress and is trying very hard to cope.
17. •Case study highlights several ethical problems:•Early diagnosis is beneficial and helpful (the patient Joan suffered fromlapses of memory for several years which went unnoticed).•Patients’ autonomy should be respected and patient should be informedof the diagnosis and then at the same time encouraged to share thediagnosis with their family and carers. (Joan’s autonomy was notrespected and instead the patient’s husband was informed of thediagnosis first and asked if the diagnosis can be broken to Joan when infact Joan was capable of understanding the information).•Confidentiality should be maintained and if the patient clearly refuses fora disclosure this should be respected.•Diagnosis should be a process, a series of steps which was not the case inCase study where it was a sudden event.•Diagnosis should be disclosed in a compassionate manner and shouldinvolve the patient maintaining dignity and a sense of hope (This did nothappen in case study where the disclosure was insensitive and not person-centered)
18. SPECIAL ISSUES IN DEMENTIA:GENETIC TESTING Several gene mutations are known to cause clusters of early-onset Alzheimer’s disease in families For some clusters, where the mutation is known, genetic testing may be helpful in conjunction with counseling The value of genetic testing is less certain in the case of apolipoprotein E alleles As long as no intervention has been shown to significantly alter the course of dementia, and the predictive value of the test is low, it does not seem advisable to recommend genetic testing Slide
19. Informed Consent
20. Informed Consent The voluntary choice of a competent patient. It is part of the concept patients’ right to self- determination. Every patient must give informed consent for any medical intervention. Informed consent gave patients the right to choose how they would be treated. Informed consent is the process by which the patient determines whether to accept or refuse the treatment offered by a physician or another clinician. The focus is not on the written consent form but on the process of communication, information exchange, and acceptance or rejection of the medical
21. The main determination for informed consent is decisional capacity. Capacity determines whether patients have the ability to consent to or refuse medical treatment. Psychiatrists are often asked to assess the quality of the patient’s decision making process, often when the patient refuses a medical intervention recommended by treating physicians. The legal equivalent of capacity is competency, which requires a judicial determination. Under the law, all adults are presumed competent. Competency may be global in certain cases (such as the case of a patient in a coma). However, capacity and competency must be evaluated in the context of a specific task. Different tasks require different abilities, information, and thresholds of understanding. Therefore, the initial inquiry for a capacity evaluation is the question, “Capacity for what?”
22. adequate information for obtaining informed consent: 1. The diagnosis and the nature of the condition being treated 2. The reasonably expected benefits from the proposed treatment 3. The nature and likelihood of the risks involved 4. The inability to precisely predict results of the treatment 5. The potential irreversibility of the treatment 6. The expected risks, benefits, and results of alternative, or no, treatment
23. All options must be described All Major adverse effects must be described consent is required for each specific procedure. The person performing the procedure should obtain the consent. Beneficence isn’t sufficient to eliminate the need for consent. Decisions made when competent are valid when consciousness is lost.
24. Common Challenges to the Practice of InformedConsent Challenge #1. A patient wants information but does not want to make own medical decisions.elderly patients often indicate that they want heir physician to give theminformation but they want the physician to make the decision. Thisasymmetry is often greatest in the case of decisions about the managementof serious and life-threatening situations. In these cases, patients willdescribe decision making built on trust and identification with their physician. Challenge #2. Quantitative information is difficult to understand.Numerical illiteracy (Many people do not understand quantitativeexpressions very well), Numerical indeterminacy (People attach variablemeanings to qualitative expressions of probability such as “rarely” and“likely.”), Biases Challenge #3. Patients may have cognitive impairments.
25. INFORMED CONSENTFOR RESEARCH The two most vulnerable populations are: Patients with cognitive impairment, who may not understand the study or their role in it Institutionalized patients, who may feel obligated Research involving vulnerable populations needs to: Be particularly well designed Focus on issues of importance to that population Slide
26. • you inform a patient about the risks and benefits of bone marrow transplantation for chronic myeloid leukemia. You fully inform the patient about the risk of transplantation, including the possibility of developing graft versus host disease. After the transplantation the patient developed graft versus host disease which is hard to control. The patient learned that there is an alternative treatment called imitanib (gleevec) which does not include the risk of graft versus host disease but which will not cure the leukemia. The patient files suit against you. What will be the most likely outcome of the suit?
27. • a man undergoes coronary angioplasty. He is informed that the artery may rupture and that there is a small chance he could bleed to death during the surgery to repair the damaged vessel. He knows he could have bypass surgery instead. He understands and chooses t he angioplasty. He dies from a ruptured blood vessel. The family files suit against you. What will be the most likely outcome?
28. • a 40 year-old man is undergoing a nasal polypectomy. In the operating room you see a lesion on the nasal turbinate that the frozen section determines to be a cancer, You have found the cancer early but will need to resect the nasal turbinate to cure it. What should you do?
29. • a 42-y-old man with leukemia repeatedly refuses chemotherapy.• He lost consciousness and his mother tells you to give the chemotherapy. What should you tell her?
30. Advance care planning
31. Advance care planning Elderly patients often have chronic and ultimately fatal illnesses. The patients are often unable to make decisions. One strategy to make these difficult decisions is to make them in advance when the patient is competent. Advance care planning describes competent patients discussing and then documenting their preferences for future medical care. This preserves patients’ self- determination even after they have lost decision-making capacity. The classic mechanism to do this is an advance directive.
32. An advance directive is a set of instructions indicating a competent person’s preferences for future medical care should the person become incompetent or unable to communicate. There are two types of advance directives: a living will and a durable power of attorney.
33. Living will: A document describing a patient’s preferences for the initiation, continuation, or discontinuation of particular forms of treatment. Durable power of attorney (DPA), health care proxy. A document that designates a surrogate (also called an “agent,” “proxy,” or “attorney-in-fact”) to make medical decisions on a person’s behalf should that person become unable to make a decision. Oral statements: that arise in conversations with family, friends, and physicians are recognized ethically, and in some states legally, as advance directives, if properly charted in medical records.
34. Persons may revoke or change their advance directive at any time. A physician who morally objects to a patient’s advance directive may choose not to comply but must facilitate the patient’s transfer to another physician.Surrogate decision making In cases of decisional incapacity, the physician may not dispense with informed consent but instead must deal with someone else who acts as a surrogate or proxy on the patient’s behalf. Surrogate decision makers should use the patient’s preferences to the extent that these are known. Using a patient’s previously disclosed preferences to make medical decisions for that patient is called a substituted judgment
35. in many cases, the patient’s preferences are unknown, or, because of significant changes in the patient’s health and well-being. In these circumstances, the guide for surrogate decision makers becomes the patient’s dignity and quality of life. This standard of decision making is called the best-interests standard, as the surrogate must assess the risks and benefits of various treatments and alternatives to treatment and choose the one that best maximizes the patient’s quality of life. Patients generally want their surrogate decision makers to use their judgment rather than be bound by the specifics of living wills.
36. • a 75-year-old man arrives at the emergency department febrile, short of breath, and confused. Many family members accompany the patient, including his wife, his siblings, his children, and his grandchildren. The physician wants to perform an emergency lumbar puncture, which the patients wife and siblings are refusing. His 25-year-old granddaughter walks up with a health-care proxy form signed by the patient designating her as the proxy She insists that you do the lumbar puncture stating that was her understanding of the patients wishes. The rest of the family, including the wife, refuses the lumbar puncture stating that they know the patients wishes better. What do you do?
37. • 78-year-old woman admitted with metastatic cancer leading to a change in mental status secondary to hypercalcemia. She has a living will in her record that states", In the event that I become unable to speak for myself for any reason I wish to express my wish that I not be intubated or placed on a ventilator under any circumstances. I also do not wish to receive dialysis .Blood testing and Antibiotics are acceptable .What should you do?
38. End of life issues
39. Refusal of treatment withdrawal and withholding of treatment patients have an ethical and legal right to refuse life- sustaining treatments including artificial nutrition and hydration. Surrogates have a similar right. Some clinicians are comfortable accepting a patient’s or surrogate’s refusal of treatment before it is initiated, yet find themselves ethically opposed to withdrawing the treatment after it is initiated. withholding and withdrawing treatment: withholding is an act of omission, not performing an action, while withdrawing is an instance of commission, performing an action. Withholding a procedure is often seen as wisely abstaining from subjecting the patient to an overly invasive intervention. Conversely, withdrawing a treatment already initiated can give the clinician a sense of responsibility for action bringing about
40. both starting and stopping treatment can be justified depending on the circumstances. Both can cause the death of a patient and both can allow the patient to die. In the cases of both withholding and withdrawing treatment according to a patient’s wishes or best interests, it is the underlying illness that is the cause of death, not the clinician’s actions.
41. • a 60-year-old man with diabetes and hypertension develops renal insufficiency to the point of needing dialysis. He is equivocal about spending the rest of his life on dialysis, but he agrees to start. The patient is not depressed and is fully alert. Six months after starting dialysis, he comes to realize very clearly that he absolutely does not wish to continue. You have no doubt that the patient has full capacity to understand the implications of this decision. What should you do?
42. Suicide, andTerminal Sedation The physician’s role at the end of life is no longer to cure or control the patient’s illness but to provide adequate relief of pain and suffering. Comprehensive palliative care is the standard of care for the dying. This includes adequate pain and symptom management, support for the patient and family, and the opportunity to achieve meaningful closure to life. Sometimes patients may ask to die to relieve their suffering. At this point, the clinician’s dual obligations of beneficence and non maleficence come into conflict. Euthanasia is the act of a physician ending the life of a patient having terminal illness or an incurable disease. The physician acts directly in bringing about the patient’s death, such as injecting a lethal dose of drugs. This practice raises strong objections. When it is done to a noncompetent patient,
43. Physician-assisted suicide is the act of providing a lethal dose of medication to a patient to self-administer. Thus, the physician is a necessary instrument but does not actively take part in the ending of the patient’s life. This practice is currently legal in only a handful of countries; in the United States, it is illegal in all states except for Oregon. Terminal sedation is the act of administering high-dose medication to relieve extremes of pain and suffering. As the name implies, the patient is sedated to unconsciousness (sedation), and this practice may hasten the death of the patient (terminal) by the impairment of respiratory function. Terminal sedation properly done is distinct from both assisted suicide and euthanasia. Medication doses are increased until sedation occurs (along with the possible risk of the
44. a 67 year old man is admitted with metastatic prostate cancer to the bones. He is in agonizing pain despite your present treatment. He has a history of COPD and the house staff are concerned that increasing pain medications will decrease his respiratory drive . What should you do?
45. Special issues
46. MALPRACTICE Physicians owe a duty of care to their patients, ethically and legally. Legal liability is a source of concern for many physicians, leading some to practice so-called defensive medicine, characterized by making decisions based in part or in whole on the desire to avoid legal liability. While physicians should be aware of the requirements of competent care and understand the foundation of malpractice liability. Several factors are associated with malpractice risk reduction First, because physicians with poor communication skills are at increased risk of being sued, improving communication between physician and patient is a key element of risk reduction. Second, acknowledging error and preserving the doctor-patient relationship are other factors associated with a reduction of the risk of
47. AGS GUIDELINES FOR RESEARCH ONPEOPLE WITH DEMENTIA Protocols that involve more than minimal risk or are unlikely to provide direct benefit should be offered only to patients able to consent, or those with an advance directive consenting to participate Surrogates can refuse participation or withdraw the person from participation, even if there is advance consent, if the surrogate determines that the protocol is not what the person intended to consent to or is not in the person’s best interest Slide
48. ETHICS IN THE NURSING HOME:TREATMENT DECISIONS Studies of attempted resuscitation in nursing homes show that it is used infrequently and is associated with low long-term survival Systematic inquiry about advance directives is required for patients in institutions receiving federal funds Regulatory agencies have encouraged enteral feeding in nursing homes, but its usefulness is questionable, especially for patients with advanced dementia Enteral feeding is not ethically used as a substitute for having staff help patients feed themselves Slide
49. ETHICS IN THE NURSING HOME:RESTRAINTS Studies show that physical restraints have little, if any, value in preventing injuries from falls In deciding whether restraints should be used, clinicians and patients’ surrogates must consider whether: The patient engages in activities that might harm others Restraints are ineffective Other measures have been tried and found to be ineffective The institution’s responsibility to protect others may require that it send the patient elsewhere Slide