Ethical Ethical Issues of Issues of

Elder CareElder Care

ObjectivesObjectives

Apply the concept of decision-specific Apply the concept of decision-specific capacity to older adults.capacity to older adults.

Apply legal and ethical principles in the Apply legal and ethical principles in the analysis of complex issues related to analysis of complex issues related to care of older adults: informed consent, care of older adults: informed consent, refusal of treatment, and advance refusal of treatment, and advance directivesdirectives

Define ethics, bioethics, ethical Define ethics, bioethics, ethical dilemma, and nursing ethics.dilemma, and nursing ethics.

ObjectivesObjectives

Describe the major ethical principles Describe the major ethical principles that have an impact on older adults’ that have an impact on older adults’ health care.health care.

Discuss the difference between Discuss the difference between personal values and professional codes personal values and professional codes of ethics.of ethics.

Apply a decision-making model to an Apply a decision-making model to an ethical dilemma in nursing practice.ethical dilemma in nursing practice.

Decision-making CapacityDecision-making Capacity

Implies the ability to understand the Implies the ability to understand the nature and consequences of different nature and consequences of different options, make a choice among those options, make a choice among those options, and communicate that choice.options, and communicate that choice.

Clinicians assess decision-making Clinicians assess decision-making capacity.capacity.

Required to give informed consentRequired to give informed consent

May fluctuate over time from transient May fluctuate over time from transient changes in ability to comprehend and changes in ability to comprehend and communicatecommunicate

Decision-making CapacityDecision-making Capacity

Competency.Competency. Legal determination by Legal determination by a judge as to mental disability or a judge as to mental disability or incapacity; whether a person is legally incapacity; whether a person is legally fit and qualified to give testimony or fit and qualified to give testimony or execute legal documents.execute legal documents.

The law presumes that all adults are The law presumes that all adults are competent and have decision-making competent and have decision-making capacity to make health care decisions.capacity to make health care decisions.

Decision-making CapacityDecision-making Capacity

Decision-specific capacity vs. global Decision-specific capacity vs. global decisional capacitydecisional capacity

May fluctuate over timeMay fluctuate over time Cognitive impairment Cognitive impairment automatic automatic

incapacityincapacity No No “gold standard”“gold standard” for capacity for capacity

determinationdetermination

Verification of Verification of Decision-making CapacityDecision-making Capacity

Required when a person is refusing or Required when a person is refusing or giving consent for treatment and/or giving consent for treatment and/or executing an advance directiveexecuting an advance directive Ability to voice a choice or preferenceAbility to voice a choice or preference Adequate disclosureAdequate disclosure Understanding of information: recall Understanding of information: recall

information; manipulate information; information; manipulate information; appreciate situationappreciate situation

Voluntary consentVoluntary consent ConsistencyConsistency

Informed ConsentInformed Consent

Can make a choiceCan make a choice Understand and appreciate the issuesUnderstand and appreciate the issues Rationally manipulate informationRationally manipulate information Make a stable and coherent decisionMake a stable and coherent decision Age-related factors:Age-related factors:

Hearing and visual impairmentsHearing and visual impairments Impaired communication: written and verbalImpaired communication: written and verbal Values and beliefsValues and beliefs Fluctuating or diminished decision-making Fluctuating or diminished decision-making

capacitycapacity

Refusal of TreatmentRefusal of Treatment

The right to refuse treatment even if The right to refuse treatment even if refusal hastens or results in their death.refusal hastens or results in their death.

Requisite capacity must be determined:Requisite capacity must be determined: Can make a choiceCan make a choice Understand and appreciate the issuesUnderstand and appreciate the issues Rationally manipulate informationRationally manipulate information Make a stable and coherent decisionMake a stable and coherent decision

Advance Directive (AD)Advance Directive (AD)

Patient Self-Determination Act (PSDA) Patient Self-Determination Act (PSDA) mandates:mandates:

1.1. Provide all adult patients with written Provide all adult patients with written information concerning care decisionsinformation concerning care decisions

2.2. Ask patients whether they have an ADAsk patients whether they have an AD

3.3. Maintain policies re: discussions of ADMaintain policies re: discussions of AD

4.4. Honor ADHonor AD

5.5. Educate patients about ADEducate patients about AD

6.6. Conduct community educationConduct community education

7.7. Do not discriminateDo not discriminate

Advance DirectivesAdvance Directives

Living WillLiving Will

Durable Power of Attorney for Health Durable Power of Attorney for Health Care (DPOAHC) or Health Care Proxy Care (DPOAHC) or Health Care Proxy (HCP)(HCP)

Guardian; conservator; proxy; health care Guardian; conservator; proxy; health care agentagent

Advance Health Care DirectiveAdvance Health Care Directive

Ethics TerminologyEthics Terminology

Ethics:Ethics: declarations of right or wrong declarations of right or wrong and what out to beand what out to be

Bioethics:Bioethics: application of ethics to application of ethics to matters of life and deathmatters of life and death

Ethical dilemma:Ethical dilemma: a difficult problem a difficult problem seemingly incapable of a satisfactory seemingly incapable of a satisfactory solution; situation involving two equally solution; situation involving two equally unsatisfactory alternativesunsatisfactory alternatives

Nursing ethics:Nursing ethics: application of ethical application of ethical principles in nursing practiceprinciples in nursing practice

Major Ethical PrinciplesMajor Ethical Principles

AutonomyAutonomy JusticeJustice BeneficenceBeneficence NonmaleficenceNonmaleficence VeracityVeracity Substituted Judgment StandardSubstituted Judgment Standard Best Interest StandardBest Interest Standard

Ethical PrinciplesEthical Principles

Autonomy – right to self-determination, Autonomy – right to self-determination, independence, and freedom.independence, and freedom.

Justice – obligation to fair to all peopleJustice – obligation to fair to all people

Beneficence – duty to act for the benefit Beneficence – duty to act for the benefit of others; “doing good” theoryof others; “doing good” theory

Ethical PrinciplesEthical Principles

Nonmaleficence – do no harm; Nonmaleficence – do no harm; protect patient from harm if they protect patient from harm if they cannot protect themselvescannot protect themselves Patient abandonmentPatient abandonment Personal relationships with patientPersonal relationships with patient Impaired practiceImpaired practice

Veracity – honest and trustworthy in Veracity – honest and trustworthy in dealing with people.dealing with people.

Ethical PrinciplesEthical Principles

Substituted Judgment Standard – Substituted Judgment Standard – surrogate decision-makersurrogate decision-maker

Best Interest Standard – decision Best Interest Standard – decision based on what health care providers based on what health care providers and/or families decide is best for that and/or families decide is best for that person.person.

Values and Codes of EthicsValues and Codes of Ethics

Personal ValuesPersonal Values

Professional ValuesProfessional Values

Code of EthicsCode of Ethics

Ethical DilemmasEthical DilemmasDecision-making ModelDecision-making Model

Collect, analyze, and interpret the dataCollect, analyze, and interpret the data State the dilemmaState the dilemma Consider the choices of actionConsider the choices of action Analyze advantages and disadvantages Analyze advantages and disadvantages

of each course of actionof each course of action Make the decisionMake the decision Evaluate the effectiveness of the Evaluate the effectiveness of the

decisiondecision

SummarySummary Concept of decision-specific capacityConcept of decision-specific capacity Verification of decision-making capacityVerification of decision-making capacity Informed consentInformed consent Refusal of treatmentRefusal of treatment Advance directivesAdvance directives Ethics, bioethics, ethical dilemmas, Ethics, bioethics, ethical dilemmas,

nursing ethicsnursing ethics Seven major ethical principles; decision-Seven major ethical principles; decision-

making model for ethical dilemmasmaking model for ethical dilemmas

Questions?Questions?