Ethical issues in geriatric care

Dr. DOHA RASHEEDY ALY
Assistant professor
Department of Geriatric and Gerontology
Ain Shams University
Ethical Issues In Geriatric Care
Summarized chapter in Hazzard textbook

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.
 Ethical dilemma arise from: conflict in values between
stakeholders. For example, an older patient with multiple
comorbidities, who values being alive regardless of his
condition, may disagree with his physician about the best way
to manage his advanced kidney disease.
 To add complexity, older adults are a heterogeneous group
with diverse values, preferences, and goals that may or

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.

Autonomy Beneficence
Nonmaleficence Justice
Ethical
principles

1. Autonomy refers to the duty to respect persons
and their rights of self-determination.
2. Beneficence refers to the duty to do good
3. nonmaleficence refers to the duty to prevent or
do no harm.
4. Justice refers to the duty to treat individuals
fairly (free of bias and based on medical need).

AN APPROACH TO THINKING
ABOUT ETHICAL DILEMMAS

Case
 Mrs. C is an 88-year-old woman with congestive heart
failure, hypertension, atrial fibrillation, and chronic
kidney disease. She lives alone in her own home.
 She was hospitalized last month for delirium secondary
to a urinary tract infection. She is admitted again this
month after a fall.
 While in the hospital, she is evaluated by physical
therapy and occupational therapy who both
recommend a short stay in a nursing home for
rehabilitation.
 Mrs. C refuses to go to a nursing home and demands
to return to her home. Her medical team insists that
going directly home is not a safe discharge plan, and

Different frameworks for approaching
ethical dilemmas exist.
1. the four-box method from Jonsen et al., in which
important information about the patient’s
medical condition, preferences, quality of life,
and other contextual features of the case, is
collected.
2. the CASES approach to ethical dilemmas

patient’s medical condition
Indications “for” and “against” the
intervention
Reflects the goals of care
patient’s preferences
Cultural, ethnic and age related
differences
quality of life
Evaluation of prior QOL
Expected QOL with and without
treatment
other contextual features
Social, legal, economic and
institutional circumstances
The four-box
method

The CASES approach
 1. C—Clarify
 a. Does this case involve an ethics concern about the right thing to do?
 b. What is the conflict in values that is leading to the concern?
 i. Values are defined as strongly held beliefs, ideals, principles, or standards that inform ethical
decisions or actions.
 2. A—Assemble the relevant information
 a. What type of information is needed?
 i. Medical facts
 ii. Patient’s preferences and interests
 iii. Other parties’ preferences and interests
 iv. Ethics knowledge
• 1. Codes of ethics, ethics guidelines, and consensus statements
• 2. Published literature
• 3. Precedent cases
• 4. Institutional policy and documents, and law
• 5. Outside ethics experts
 b. Which stakeholders need to be interviewed?
 3. S—Synthesize the information
 a. Analyze the information
 i. Review the range of ethically justifiable options
 ii. Weigh the different potential outcomes and the impact of these outcomes on the stakeholders
 4. E—Explain the synthesis
 a. Communicate the ethically justifiable options to the key stakeholders
 5. S—Support the consultation process
 a. Follow up with stakeholders

Question: What is the ethically
appropriate discharge for Mrs. C?
 The first step of the CASES approach is to Clarify
whether the dilemma is really about ethics or
something else, such as a legal issue. This is done
by identifying whether there is a conflict in values
between two of the involved stakeholders.
 In the case of Mrs. C, the conflict in values is between
Mrs. C, who doesn’t want to go to a nursing home for
rehabilitation, but wants to go home, and her medical
team who believes that sending her home would be
harmful to her.
 This dilemma also can be viewed as a conflict between
ethical principles. In the case of Mrs. C, the conflict in
principles is between honoring Mrs. C’s autonomy/self-
determination and promoting her clinicians’

In the second step of the CASES approach,
information relevant to the case is
Assembled.
 This information includes medical information, patient preferences, other
parties’ preferences, and ethics knowledge.
 In the case of Mrs. C, we already know that she has multiple medical
problems, lives alone, is in her second hospitalization, and is staunch in
her refusal to go to a nursing home for rehabilitation.
 Knowing her reason for refusing this would be helpful.
 For example, she might tell us that her husband died in a nursing home
after a prolonged decline from dementia, and that she gets flashbacks and
panic attacks whenever she enters a nursing home. Or, she might tell us
that she needs to get home to care for her frail neighbor
 We would want to hear more from Mrs. C’s medical team about their
concerns, and what they believe they can and cannot allow their patients
to do.
 look at the hospital’s policies around informed consent and refusal
of care,
 look in the literature to see if anyone has written about this issue.
 In assessing her capacity, it would be important to find out if she
understands the risks and benefits of going to a nursing home for
rehabilitation versus going home directly

Third step: Synthesize the
information
 we would need to begin to consider the
different possible options and the impacts on
stakeholders of each option.

Fourth step: Explain the
synthesis
 Explain the risks and benefits of going to a
nursing home for rehabilitation versus going
home directly

Fifth step: Support the consultation process
 If Mrs. C has decisional capacity to make the decision to go
home, her medical team cannot force her to go to a nursing
home against her will. In light of this, her team should not
simply send her home, but should think about ways to
promote her continued recovery and safety at home.
1. This might include arranging for more resources in her home,
such as a visiting nurse/PT/OT, Meals on Wheels.
2. a product she could use to quickly call for help in the future.
3. Or it might involve brainstorming about how to get help for
her frail neighbor, so she would feel more comfortable going
to the nursing home for rehabilitation.
 If Mrs. C does not have decisional capacity to make the
decision to go home, then the medical team will need to
involve her legal surrogate decision maker to help make this
decision.
 Since some states have laws forbidding placement of
individuals in nursing homes against their will, finding a

 occurs when you are prevented from doing what you
believe is right because of institutional barriers, and are
forced to act contrary to your core values.
 one’s level of distress does not return to baseline after
experiencing an episode of moral distress, but that, with
each case, one’s “moral residue” increases to a new
baseline. Thus over time, there is a crescendo in a
clinician’s moral residue. This crescendo of moral residue
and “untreated” moral distress can lead to burnout, to
individuals leaving their positions, and even to individuals
leaving their professions. This can be psychologically
costly for individuals and financially costly for
institutions.

Clinical situations
• Providing unnecessary/futile treatment
• Prolonging the dying process through aggressive
treatment
• Inadequate informed consent
• Working with caregivers who are not as
competent as care requires
• Lack of consensus regarding treatment plan
• Lack of continuity of care
• Conflicting duties
• Using resources inappropriately
• Providing care that is not in the best interest of
the patient
• Providing inadequate pain relief
• Providing false hope to patients and families
• Hastening the dying process
• Lack of truth-telling
• Disregard for patient wishes
Internal constraints
• Perceived powerlessness
• Inability to identify the ethical issues
• Lack of understanding of full situation
• Self-doubt
• Lack of knowledge of alternative treatment plans
• Increased moral sensitivity
External constraints
• Inadequate communication among team
members
• Inadequate staff and increased turnover
• Lack of administrative support
• Policies and priorities that conflict with care
needs
• Following family wishes of patient care for fear of
litigation
• Compromising care due to pressures to reduce
costs
• Hierarchies within health care system
• Lack of collegial relationships
• not involved in decision making
• Compromised care due to insurance pressure or
fear of litigation

Ethical dilemma leading to moral distress
 Mr. G is a 78-year-old skilled nursing facility resident with multiple medical
problems, including mild dementia, who is admitted to the intensive care
unit with pneumonia and possibly sepsis.
 He is intubated. Over the next 2 weeks, he develops acute respiratory
distress syndrome (ARDS), Clostridium difficile colitis, and a pressure ulcer.
His renal function is deteriorating. He remains delirious and unable to
participate in medical decision making.
 Mr. G’s advance directive states that he wouldn’t want life-prolonging
measures for a terminal condition, and would want care focused on comfort.
His wife, whom he designated as his health care agent through a Durable
Power of Attorney for Health Care, insists that treatments with the goal of
life prolongation be continued.
 His nurses are concerned that his prognosis is poor and his preferences
aren’t being honored. His physicians say he isn’t “terminal” yet.

 His nurses are concerned that he has pain. They note that he grimaces when
they care for him. His wife refuses for him to have pain medications because of
a fear that they will prevent him from waking up.
 When the doctors, nurses, social workers, and the chaplain have tried to talk to
Mrs. G about his goals of care or his pain management, she becomes agitated
and threatens lawsuits.
 Team members are frustrated. There are rumors that Mrs. G is demented, in
denial, revengeful, and wanting to keep him alive for his pension.
 Some have commented that scarce resources are being wasted in keeping him
alive.
After recognizing that a case is causing moral
distress, what can health care professionals do
about it?

1. One helpful intervention is for the team to talk
about the case and the aspects of the case that
are giving each of them moral distress.
2. Self-care interventions for individuals also may be
helpful.
3. Finally, if organizational factors are leading to
moral distress in staff, these need to be brought to
the attention of the organization’s management.

Competence and decision-making
capability

 A 79-year-old man with mild dementia has positive
results on Hemoccult testing of stool samples. His
physician recommends colonoscopy. The patient
understands and can repeat in simple terms the
rationale for the procedure as well as its risks and
benefits

 There is an important difference between the
concepts of competence and decision-making
capability.
 clinician may evaluate a patient’s capacity to
make decisions, but competence is a legal term
that implies that the individual has been deemed
competent or incompetent by a court of law.
 Competence refers to a person’s ability to act
reasonably after understanding the nature of the
situation being faced. Someone not competent to
act on his or her own behalf requires an agent to
act for him or her.

 In the case of dementia, a person may or may not be
capable of understanding and interpreting complex
situations and making rational decisions. Intellectual
deficits are spotty.
 A person may get lost easily or forget things but still
be able to make decisions with appropriate
prompting.
 The presence of a formal diagnosis of dementia,
even by type, may not be a sufficient indicator of the
individual’s ability to comprehend and express a
meaningful preference. Just as it is wrong to
infantilize such patients by directing questions to
others who are quicker to respond, so, too, might it
be inappropriate to prejudge their ability to participate
in decisions about their own care.

 Determining cognitive ability and decision-making
capacity is not easy. One must distinguish memory from
understanding.
 Decisional capacity is predicated on four elements:
 (1) understanding, or the ability to comprehend the
disclosed information about the nature of the
situation/medical problem, the procedures involved in
testing for example, and the risks and benefits of
undergoing or not undergoing testing or treatment;
 (2) appreciation of the significance of the disclosed
information and the potential risks and benefits for one’s
own situation and condition;
 (3) reasoning, which involves the ability to engage in a
reasoning process about the risks and benefits of a
procedure or treatment; and
 (4) choice, or being able to choose whether or not to
undergo further testing or treatment

 Patients who have DMC have an absolute and
fundamental right to make their own medical decisions,
whether or not others agree with their decisions, even if
the decisions lead to bad outcomes (including death).
 The reason to assess DMC is to answer the question: “should
we allow this patient to make this medical decision, under
these circumstances?” The focus is NOT global capacity, but
the patient’s ability to decide about a particular proposed
intervention or treatment under particular conditions and
circumstances.
 “Capacity” refers to a patient’s mental ability to participate in
decision-making, can wax and wane, and is determined by
healthcare providers at the bedside. “Competency” is a legal
term, refers to a long-standing, global condition, and is
determined by a judge (usualy with advice from physicians).

Four Questions to Assess Decision Making Capacity:
1) Can the patient demonstrate the ability to communicate a
choice?
“Have you decided whether to go along with your doctor’s suggestions?”
2) Does the patient understand his or her medical condition and the
relevant facts?
“Please tell me in your own words what your doctor told you about your
condition, his or her recommendation, the risks and benefits of the proposed
intervention, and the alternatives.”
3) Does the patient understand the available options and the
consequences of his or her decision?
“What do you think will happen to you if you are not treated? What do you
think will happen if you are treated? Why do you think your doctor has
recommend (x) to you?”
4) Is the decision based on reasoning consistent with the patient’s
values/ preferences?
“How did you reach your decision? What factors were important to you in
reaching the decision?” Make sure the conclusions follow logically from the
premises.

CONFIDENTIALITY AND
MANDATORY REPORTING LAWS

CASE 1
• 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?
CASE2
• 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?

year-old well-known public figure presents for a physical
examination. During the interview, the patient shows substantial
cognitive impairment. The patient’s spouse, who is present during
the interview, confirms that the patient’s memory has been
impaired for several years.

CONFIDENTIALITY AND
MANDATORY 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

EXCEPTIONS TO THE DUTY OF
CONFIDENTIALITY
1. Patient permission (waiver)
2. Danger to others
3. Mandatory or permissive reporting statutes
4. Legal process (court order)
5. Treatment, payment, and health care operations.

 Examples of situations in which public policy
considerations limit doctor-patient confidentiality include
mandated reporting of infectious diseases and suspected
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 a patient.

 Questions about whether or not to report concerns
about an older individual’s driving are answered by
weighing the clinician’s duty to protect the patient’s
safety, with the duty to maintain confidentiality, and the
duty to protect the public. Some US states have
mandatory reporting requirements.

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.
 In this era of patient-centered care, patients should be
offered the opportunity to learn about their medical
conditions. However, patients also have the right to decline to
hear about their conditions
 Diagnostic disclosure depends on:
1. the capacity of the persons to understand and appreciate the
diagnosis,
2. their expressed desire to know what is wrong,
3. and the emotional and moral impacts that this knowledge may
have.

One critical step in living with an illness is to understand
and appreciate 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 understanding because it refers to integrating
knowledge into one’s sense of self.

 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.

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.

Diagnostic Disclosure of
Alzheimer’s Disease
 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

Disclosing the diagnosis of Alzheimer’s disease
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.

The SPIKES Approach to Breaking Bad News
 1. S—Setting up the interview
 a. Find a private, quiet room with room for all participants to sit down
 b. Encourage family and involved others to participate
 c. Minimize distractions—turn off sound from pagers and phones
 d. Establish rapport with the patient with eye contact and touch
 2. P—Assessing the patient’s Perception
 a. What do the patient and family understand about the patient’s medical condition?
 b. Correct any misperceptions
 3. I—Obtaining the patient’s Invitation
 a. Ask the patient and family how much information and what kind of information
they want or don’t want
 4. K—Giving Knowledge and information to the patient
 a. Start with a statement that you’re about to share bad news
 b. Share the information succinctly in lay language
 c. Allow time for the patient and family to absorb this information
 5. E—Addressing the patient’s Emotions with empathic responses
 a. Acknowledge and validate the patient and family’s emotional response
 6. S—Strategy and Summary
 a. Summarize the conversation and answer questions
 b. Develop a clear plan for what comes next

•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.

•Case study highlights several ethical
problems, explain??

1. Early diagnosis is beneficial and helpful (the patient Joan
suffered from lapses of memory for several years which went
unnoticed).
2. Patients’ autonomy should be respected and patient should be
informed of the diagnosis and then at the same time
encouraged to share the diagnosis with their family and carers.
(Joan’s autonomy was not respected and instead the patient’s
husband was informed of the diagnosis first and asked if the
diagnosis can be broken to Joan when in fact Joan was capable
of understanding the information).
3. Confidentiality should be maintained and if the patient clearly
refuses for a disclosure this should be respected.
4. Diagnosis should be a process, a series of steps which was not
the case in Case study where it was a sudden event.
5. Diagnosis should be disclosed in a compassionate manner and
should involve the patient maintaining dignity and a sense of
hope (This did not happen in case study where the disclosure
was insensitive and not person-centered)

Case 2
• Mr. W is an 83-year-old man who is brought to see his
primary care provider (PCP) by his wife. She confronts the
physician outside the examination room and expresses
concern that her husband has become more forgetful and
no longer is able to pay their bills. She remarks, “If he has
Alzheimer disease, please don’t tell him.”

• it would be appropriate to understand Mrs. W’s reasons for not
wanting her husband to know his diagnosis. Perhaps he has asked her
on multiple occasions not to ever tell him if he develops dementia,
because of a previous experience with a family member who suffered
from dementia. In this case, it might be appropriate not to share this
information with Mr. W. Ultimately, however, he has a right to this
information, if he wants it. After hearing her reasons, we could use the
SPIKES approach to talk to Mr. W. He would be asked about his
understanding of his current situation and whether he would want
information or not.
• In the case of dementia, it is appropriate to share information about
the diagnosis with a patient with mild dementia who has decisional
capacity to make the decision about whether or not to hear the cause
of his memory loss. It might not be appropriate to repeat this
information over and over to a patient with more advanced dementia,
who might experience the emotional reaction to receiving this
diagnosis multiple times or might not be able to fully understand what
this means.

 A recent systemic review of 23 articles with over
9000 participants found that 91% of cognitively
intact people and 85% of cognitively impaired
people wanted to know if they had dementia.
 A second study found that there were no increases
in rates of depression or anxiety after people
learned of a dementia diagnosis.

• 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?

An 82-year-old woman presents with a palpable breast mass.
Biopsy reveals breast cancer. The patient is seen by a surgeon
who tells her that she needs surgery, hands her a consent form,
asks her to read and sign it, and leaves the examination room.
The surgeon’s resident returns later to retrieve the signed
form.

• 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 the angioplasty.
• He dies from a ruptured blood vessel.
• The family files suit against you. What will be the most likely
outcome?

• 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?

• 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?

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 intervention.

 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?”

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

1. All options must be described
2. All Major adverse effects must be described
3. consent is required for each specific procedure.
4. The person performing the procedure should obtain
the consent.
5. Beneficence isn’t sufficient to eliminate the need for
consent.
6. Decisions made when competent are valid when
consciousness is lost.
7. In emergencies, consent is presumed when an
advance directive (AD) or a surrogate is unavailable.
In emergencies, consent is presumed when an
advance directive (AD) or a surrogate is unavailable.

Common Challenges to the Practice of Informed
Consent
 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 them
information but they want the physician to make the decision. This
asymmetry is often greatest in the case of decisions about the management
of serious and life-threatening situations. In these cases, patients will
describe 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 quantitative
expressions very well), Numerical indeterminacy (People attach variable
meanings to qualitative expressions of probability such as “rarely” and
“likely.”), Biases
 Challenge #3. Patients may have cognitive
impairments.

INFORMED CONSENT
FOR 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

•Mrs. Y is a 69-year-old woman who was recently
hospitalized after a fall, which was attributed to
amyotrophic lateral sclerosis (ALS), a new diagnosis
for her. She comes to her PCP, Dr. G, for follow-up.
She expressed concern about her future.
•Question: What is appropriate for her PCP to discuss
at this visit?

• Having recently received a diagnosis of ALS, Mrs. Y is
understandably concerned about her future.
• Her physician may want to explore her knowledge of and
concerns about ALS, and engage in ACP to understand her
preferred care preferences and goals of care.
• Use of empathic statements by Dr. G may be helpful.
• Dr. G may believe it is important for an ALS specialist to
engage in ACP conversations with Mrs. Y but if she has a
relationship with Dr. G and trusts him, it is appropriate for
him to begin these conversations, and to readdress these
issues as her condition progresses. To promote good quality
of care, he should share this information with the ALS
specialist.

• As part of ACP, Mrs. Y first can be encouraged to identify who
she would want to make medical decisions for her in the future,
if she was unable to make her own decisions. She should
appoint that person as her legal future decision maker through a
durable power of attorney for health care (DPOAHC).
• She should inform her surrogate of his/her future role, give
him/her a copy of the document, and explain that this only takes
effect if she loses the ability to make her own decisions.
• Next, Dr. G and Mrs. Y can discuss her general preferences for
care, such as whether she would want life-sustaining treatments
in general scenarios, such as permanent coma or terminal
illness.
• They also may want to address her care preferences in more
specific illness scenarios that occur commonly in ALS, such as
dysphagia and respiratory failure.
• Mrs. Y, her loved ones, and her care providers also may want
to use available resources to facilitate ACP

• ACP is a process, and will rarely be completed in one visit.
Dr. G may want to continue to discuss these issues
periodically, and attempt to include her designated
surrogate decision maker(s), and involve others.
• If she does not complete an advance directive, Dr. G
should document these conversations in the medical
record, and share them with Mrs. Y’s ALS specialist. (oral
statements) To ensure that this documentation helps guide
her future care, it should be easy to locate in the medical
record.
• Mrs. Y may identify that her current goal is to maintain her
independence for as long as possible. She also may
identify that when she reaches the end stage of ALS, she
would then want her goal to shift to maximizing her
comfort. Since people can change their minds and goals, it
will be important to revisit her preferred goals as her
disease progresses.

• 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 patient's 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 patient's wishes.
• The rest of the family, including the wife, refuses the lumbar
puncture stating that they know the patient's wishes better. What
do you do?

• 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?

Advance care planning
 Patients with decisional capacity have the right to make
decisions that their medical teams and families don’t
agree with.
 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 may 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.

 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.
 Of note, people with some cognitive
impairment may be able to designate a
decision maker through a DPOAHC, even
if they are not able to think abstractly about
their future care preferences

 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.

 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.
 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

HIERARCHY OF SURROGATE
DECISION MAKING
 New York Family Health Care Decisions Act, 2010
Decisions for adult patients by surrogates should
the patient be incapable, in order of priority:
1. Durable power of attorney for health care
decisions (or health care agent)
2. Court-appointed guardian
3. The spouse or domestic partner
4. An adult child
5. A parent
6. A brother or sister
7. A close friend

shared decision making
 Through a process of shared decision making,
patients or their surrogates share information about
their goals and care preferences with clinicians, and
their clinicians share pertinent medical information
and make care recommendations based on the
patient’s values and goals

 POLST form ,also called MOLST, MOST, POST:
Physician Orders for Life-Sustaining Treatment Physician
orders for care, usually including sections about
resuscitation, preferred levels of care, use of antibiotics,
and use of artificial feeding. They differ from advance
directives because they are physician orders
 POLST forms usually contain four categories of
information.
1. People designate their resuscitation preferences in one
section.
2. In the second section, people choose between three
different levels of care (comfort care, limited additional
interventions, including use of IVs and hospital-level care,
and full treatment, such as ICU-level care).
3. A third section designates preferences for receiving

Goals of care:
1. Cure
2. Life prolongation
3. Participation in a future event
4. Remain independent
5. Maintain clear thinking
6. Maximize comfort

STANDARDS FOR MAKING DECISIONS
WHEN PATIENTS LACK DECISION-MAKING
CAPACITY
 Advance directives
 Oral statements to family members or friends
 Oral statements to physicians
 Written documents
 Surrogate decision
 Substituted judgments
 Best interests of the patient
 Shared decision making

• Mr. H. is an 84-year-old man with Parkinson disease diagnosed
approximately 8 years ago. He has relied increasingly on his wife, Rose,
for help, as he has become more dependent with his activities of daily
living (ADLs) and (IADLs) over the last year. She has noticed that he
appears slightly disoriented, often in the evenings. She notes that he has
been more unsteady, and has sustained approximately three falls in the
last few months (with no apparent injuries).
• Last evening, Rose heard a thud and found Robert on the bathroom floor,
disoriented and in pain. She called 911, and he was taken to the
emergency room (ER) for evaluation.
• In the ER, Mr. H appeared obtunded and minimally responsive. He was
found to have a moderate-sized subdural hematoma.
• Neurosurgery was consulted. Although Mr. H had not formally appointed
a health care agent through a DPOAHC decisions, given the severity of
the his condition and the urgency with which a decision needed to be
made, the neurosurgery team discussed his treatment options with Rose,
who was at the bedside. They explained to Rose that that they could try
to surgically evacuate the hematoma, but that it would be a high-risk
procedure, with a fairly low chance of benefit.
• They explained that options included either going ahead with the
subdural evacuation attempt, or focusing on his comfort with the
understanding that his prognosis was likely hours to days if this option
was pursued. The neurosurgery team felt that the decision was up to
Rose, as she knew him best, and asked her to let them know what she
decided.

•What concerns do you have about this decision-
making process as described?
• The physicians involved in Mr. H’s case perceive that a decision
regarding surgical intervention needs to be made quickly, based on
Mr. H’s clinical presentation and neuroimaging. It is unclear
whether the physicians from the neurosurgical team or the ER team
have elicited any information about Mr. H’s preferences, which
might be evident in an advance directives or prior conversations
with Rose. It also is not clear whether Mr. H had actually appointed
a legal DPOAHC or health care proxy for health care decisions.
These points would need to be clarified for effective clinical
decision making to take place

• Given Mr. H’s subdural hematoma and obtunded mental status, he
does not possess the decisional capacity to participate in an
informed consent process, rendering him unable to participate in a
discussion regarding his treatment choices. Therefore, a surrogate
decision maker needs to step in to make decisions under the
principles of substituted judgment or best interests if one is available
(further discussion below). Typically a surrogate is a person
designated by the patient (eg, DPOAHC decisions), a court-
appointed guardian, or a close family member if the former two
designees do not exist.
• If you were a member of the neurosurgery team, a primary concern
on your part would hopefully be to further understand what Mr. H’s
care preferences or wishes would be, if he were able to decide for
himself. Once the neurosurgery team has understood that Mr. H has
not assigned a formal DPOAHC decisions, they would want to ask
whether he has had conversations with Rose or other family or
friends about his preferences for care if he was to become gravely ill.
Oral statements to family, friends, or to physicians can serve as
advance directives. Written documents such as living wills also can
serve as an advance directive and reflect the patient’s care
preference

• In Mr. H’s case, it appears that the neurosurgical team is leaving the
decision about whether or not to intervene surgically up to Rose.
• There are several problems with this approach, including the notion
of having a surrogate make a medical decision unilaterally or in
isolation without the medical background and knowledge to truly
assess surgical risk and anticipate consequences. Rather, a shared
decision-making approach would be preferable, in which the
surrogate shares information about the patient’s wishes,
conversations, and values, medical team shares medical
expertise. The medical team then makes recommendations based
on information about the patient’s values and goals. This serves to
facilitate a more informed decision-making process while mitigating
the potential effect of postdecision surrogate guilt, and the very
real chance of complicated bereavement, often characterized by
the development of depressive symptoms and even posttraumatic
stress disorder after the patient’s death.

• The social worker in the ER finds out that Rose has known Mr. H for the
last 20 years, and states that they have been “together” for the last 15
years. Rose explains that he always enjoys gardening and walking his dog,
Lucy. In the past, the patient had mentioned to Rose that he would not
want any “heroics” and that “if it’s my time, let me go!” When asked
about other family members, Rose states that Mr. H has a son in his 40s
and a daughter in her 30s. Both live out of state. Mr. H has had monthly
contact with his daughter, but his older son has been estranged for the
last 10 years.
• Mr. H does not have a living will, and has not appointed a DPOAHC
decisions. He did have conversations about his general end of-life wishes
with Rose. The attending neurosurgeon explains to Rose that the patient
has a very slim chance of meaningful recovery. Given Mr. H’s previously
expressed wishes regarding end-of-life care and his prior statement that
he would want to avoid “heroics,” the decision is made to forego surgical
intervention. Comfort-focused care is begun.
• Later that night, the neurosurgery resident is paged by the hospital
operator who connects him to Mr. H’s daughter, Angela. She lives out of
state and is very concerned about her father. After hearing the
explanation of her father’s situation, Angela requests that “everything be
done” including reconsideration of a subdural hematoma evacuation.
• Should Angela’s request be considered?

• Regarding Mr. H’s case, conducting a family meeting with Rose and
Angela would most likely be the next step, even if this happens
through a conference call with both parties involved. If reasonable
consensus could not be reached, determining a legal decision maker
may involve adhering to state law regarding surrogate hierarchies if
the state he resides in has such a law, or federal law in the case of
veterans receiving care within a VA facility. Ethics committee
involvement would be important if initial efforts at communication
with family members and surrogates are not fruitful in garnering
support and consensus in a manner that best reflects Mr. H’s
previously stated wishes.

• 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?

• Mrs. S is an 82-year-old woman with mild dementia, coronary artery disease,
hypertension, and peripheral vascular disease.
• She misses a meal in the dining room of her assisted living facility and is
found in her apartment lethargic and confused. She is sent to the hospital,
admitted to the ICU, and diagnosed with urosepsis. She has a POLST form,
which accompanies her to the hospital, with preferences for do not
resuscitate (DNR) status, limited additional interventions, antibiotics to
prolong life, and a trial of use of a feeding tube.
• Despite aggressive care in the ICU, she remains delirious. Over the next 2
weeks in the ICU, she suffers a non-ST segment elevation myocardial
infarction (MI), develops a pneumonia thought secondary to aspiration, and
her kidney function worsens.
• Her adult children, who are her legal decision makers, are given regular
updates, but are overwhelmed by the numerous medical decisions they are
asked to make including whether to insert a temporary feeding tube in her
nose, followed later by whether to insert a more permanent tube in her
stomach, and whether to start dialysis. Although they had initially told the
ICU to do “everything” to make their mother better, short of resuscitating or
intubating her, they begin to wonder if they are doing the right thing. They
wonder how long their mother would want this level of care continued.
During a routine meeting with the family, the ICU team uses the term
“futile” and recommends that they change the goal of care to focus on
maximizing their mother’s comfort.
• What should the family and ICU team consider in deciding how to proceed?

• Mrs. S’s clinicians begin to talk about her situation being “futile.”
• This term is used by health care professionals, but not by lay
people, and therefore should not be used in routine
conversations with patients or their loved ones. The term is also
commonly used when clinicians don’t believe that continuing on
the current trajectory is “worth it.”
• Different definitions of futility exist, including quantitative futility
(very low probability of survival) and qualitative futility (patient’s
quality of life is below an acceptable standard). These
definitions can be problematic because clinicians cannot
accurately predict a patient’s chances of survival, and may not
be able to separate their own views about acceptable quality of
life from the patient’s view of his/her quality of life.

• a change in the focus of her care from life prolongation to comfort
care
• consulting a palliative care team may be helpful

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
the patient’s death and can be regarded as an act of
abandonment.
 Although withholding and withdrawing care are ethically

 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.

 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?

• Mr. P is a 90-year-old man with widely metastatic prostate cancer
receiving hospice services in a nursing home. He continues to have
severe bone pain from his metastatic disease despite the use of
opioids, steroids, pamidronate injections, and a course of palliative
radiation.
• As his opioid doses are increased, he develops myoclonus and
confusion. Rotation to two different opioids over the next 2 weeks
is minimally effective. His confusion worsens, becoming a
hyperactive delirium with bouts of yelling and attempting to climb
out of bed. Addition of antipsychotic medications is only slightly
effective. His family and the nursing staff are distressed about his
situation and their inability to ensure his comfort and safety.

Suicide, and
Terminal 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,

 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.
 Patients may raise the topic of PAD as a way to begin a
conversation about the end of life. Clinicians should
view this as an opportunity to talk about sources of
intractable suffering and fears about dying regardless of
whether or not they live in a state where the practice is
legal.

Palliative sedation (legal in
USA)
 Palliative sedation: Lowering of patient consciousness
using medications for the express purpose of limiting
patient awareness of suffering that is intractable and
intolerable.
 Terminal sedation is an older term for palliative
sedation, fallen out of favor because “terminal” was
misinterpreted to imply that the sedation itself caused or
hastened death.
 Proportional palliative sedation is the process of
reducing consciousness only as much as needed to
reduce patient suffering. Patients may only be mildly
sedated, not necessarily sedated to unconsciousness.
 Deep continuous sedation is used to describe the last
step of a gradual process of palliative sedation in which

Respite sedation
 Sedation induced for a predetermined period
of time to give the patient respite from
intractable refractory suffering. At the end of
that period of time, sedation is reduced to
allow the patient to awaken and assess
whether the symptom burden has lifted, and
to determine if sedation is still required to
effectively address suffering.

Continuous sedation until death (CSD):
 Act of reducing or removing consciousness of a
terminally ill patient until death, “suggests that the
physician chooses a priori to sedate a patient until
death without prospectively monitoring the result
or modifying the approach as needed on the basis
of clinical conditions

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
1. 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.
2. Second, acknowledging error and preserving the doctor-patient
relationship are other factors associated with a reduction of the
risk of malpractice litigation.
3. recognition of individual and systemic factors that contribute to
errors, maintenance of good clinical records, consultation with
colleagues, and avoidance of “overlegalization” of clinical
practice.

ELEMENTS OF A PROFESSIONAL
NEGLIGENCE CLAIM
1. Duty owed by professional/provider to the
patient
2. Breach or violation of duty
3. Damage or injury to the patient
4. Causal (both general and proximate) link
between the professional/provider breach of
duty and the injury suffered by the patient

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

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

strategy for management specific residential
care issues:
Resident wandering or resisting basic care, such as bathing:
Look at the root cause of these behaviors and try to address
the underlying needs, wants or fears underlying the behaviors
rather than using medications, ie, enlist family to visit frequently,
bring photo albums and other items that will make resident feel
more at home.
Balancing resident’s wishes against practical issues of
available resources e.g. Resident prefers daily showers, but
staffing levels do not permit this frequent bathing schedule.
 Work closely with staff and residents to approach residents’
wishes as closely as possible within the constraints of the
facility’s resources and staffing levels. Restructure staff tasks to
enable person-centered care as much as possible. Explain
staffing constraints to resident

Balancing resident’s care preferences against those of
his/her surrogate decision maker
 Resident’s advance directive requests comfort care if
diagnosed with terminal illness and resident has end-stage
dementia, however, family wishes to transfer resident to
hospital for pneumonia.
 Suggested strategy for management: Educate families on
complications that are expected to arise during trajectory of
dementia as part of a discussion of patient and family goals,
establish trust and rapport with families, and keep families
well informed during the course of nursing home stay.
 Promoting quality end-of life care vs helping residents
to have financial coverage for their care
 Resident with metastatic cancer may not be able to
have radiation therapy for painful bony metastases if
he/she is on hospice care.
 Suggested strategy for management: Work closely with
hospice provider and facility to identify best way to

Quality indicators for NH
 Pressure sores
 Weight loss
 Antipsychotic prescription in absence of psychotic features
 Physical restraints
 Incidence of new fractures
 Prevalence of falls
 Prevalence of behavioral symptoms affecting others
 Prevalence of indwelling catheters
 Prevalence of dehydration
 ADL loss
 Prevalence of depression
 Incidence of decline in range of motion
 Prevalence of pain
 Incidence of worsening locomotion
 Incidence of worsening depression or anxiety

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

• Mr. J is an 89-year-old man living temporarily in a
skilled nursing facility where he is receiving physical
and occupational therapy after he fell and sustained a
patellar fracture. He is doing well, and the
interdisciplinary team informs you that he is close to
ready for discharge home. He lives in a one-story
home with his wife. He drives to the neighborhood
shopping center to meet his friends for lunch, buy
groceries, and do other chores. During your
assessment, you note that his memory is mildly
impaired, with only one out of three items recalled
after 5 minutes, and he has difficulty with attention. His
clock-drawing test is markedly abnormal, with impaired
spacing and numbering.
• Questions for the interdisciplinary team: Should he still be driving? What
do we do about it?

 patient is usually upset at the loss of
independence and autonomy that driving
provides.
 Common reasons for recommending driving
cessation are epilepsy, stroke, dementia, visual
impairment, and medication adverse effects

STRATEGIES TO EMPLOY WHEN WORKING WITH OLDER
ADULTS REGARDING DRIVING CESSATION
 Patient threatens to sue physician if reported to
Department of Motor Vehicles:
1. Clearly document how the patient was determined to
be an unsafe driver (driving fitness evaluation,
assessing driving-related skills [ADReS] battery,
driving rehabilitation referral, medications, etc).
2. Advise patient that the state has the ultimate
responsibility to determine licensing.
3. If physician is mandated to report in that state,
physician must report. The physician should also
advise the patient of this.
4. Consult malpractice insurance or legal counsel to
determine degree of risk (physicians generally run

 Physician identifies patient as an unsafe driver, state
does not have mandatory reporting laws:
1. Consider referring the patient to a driver’s rehabilitation
specialist.
2. Attempt to counsel patient to stop driving voluntarily without
revocation of license.
3. If patient refuses to stop driving, physician must weigh breach of
confidentiality vs potential injury to patient and others from a
crash.
 Patient had license suspended, but continues to
drive
1. Talk to the patient about why he or she continues to drive.
2. Involve social work to provide transportation resources and the
patient’s family to find alternative transportation.
3. Counsel patient that he or she is breaking the law, cite concerns
about patient’s safety, and discuss consequences of a crash
(being injured, injuring others, financial and legal implications).
4. Assess patient for cognitive impairment and insight; counsel
surrogate decision makers regarding responsibility to prevent
patient from driving.
5. Report patient as an unsafe driver again.

 Patient threatens to find a new doctor if physician
reports to Department of Motor Vehicles
1. Diffuse situation by reiterating how unsafe driving
determination was made.
2. Convey concern for patient’s safety, and safety of others
who would be affected if patient crashed.
3. Remind patient that driving safety is part of good health
care as much as other physician responsibilities.
4. Encourage patient to be evaluated by a driving
rehabilitation specialist.
5. Emphasize that the state Department of Motor Vehicles
makes the final determination of driving safety.
6. Maintain professional behavior by not expressing
hostility even if he or she seeks a new physician.

AGS GUIDELINES FOR RESEARCH ON
PEOPLE 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

 An 86-year-old cognitively intact woman with coronary artery
disease and atrial fibrillation presents with a massive stroke. For
2 months, she remains unconscious with complete hemiplegia.
Her chance of significant neurologic recovery is virtually nil. She
has no AD. Her family has strong religious convictions and
requests a permanent feeding tube. While this discussion
occurs, she becomes febrile and is diagnosed with pneumonia.
 The children insist that the doctors must under no
circumstances tell the patient’s elderly husband her bleak
prognosis, because “the information would surely kill him.” He is
cognitively intact and keeps asking about his wife’s condition.
 Questions
1. Is it appropriate to insert or refuse to insert a feeding tube in this patient?
2. Should her pneumonia be treated?
3. How should one respond to the husband’s queries?

 An 84-year-old woman with mild dementia and
compensated congestive heart failure is admitted to a
nursing home. Her husband, the surrogate decision-
maker, presents the attending physician with a signed
and witnessed that states that under no
circumstances does she want resuscitation, antibiotic
therapy for life-threatening infection, or to be
transferred to an acute care hospital.
 Questions
1. How should the staff respond to these requests, especially if
they go against their own religious convictions?
2. The patient falls ill and is in a stuporous state secondary to
sepsis. How should the staff respond?

 An 87-year-old man with advanced metastatic lung
carcinoma admitted to an acute hospital is fed via a
gastrostomy tube and aspirates in the middle of the
night. He is intubated and put on mechanical ventilation.
The morning of the senior physician’s round, the
children informed her that their father had told all of
them that he would never want to end his days on a
machine, as did his late wife, who died of intractable
congestive heart failure several months ago. There is
no AD.
 Questions
1. Should he have been intubated?
2. Can life-support be discontinued in accordance with
the patient’s request expressed directly or communicated
to the team by the children?

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