1.Ethical Issues In Geriatric Care Dr. DOHA RASHEEDY ALY Lecturer of Geriatric Medicine Department of Geriatric and GerontologyAin Shams University

2. Introduction: The competent practice of geriatric medicinerequires physicians and other clinicians to masterboth a body of knowledge about how to diagnoseand treat geriatric health conditions and an ethicto apply this knowledge to the care of theirpatients. the ethics of patient care focus on using theprinciples of respect for autonomy andbeneficence. 3. Introduction: Medical practice occurs within a legal andregulatory context. it is critical for clinicians to be familiar with thespecific requirements and standards in thejurisdictions in which they practice. As a general rule, it is most important thatphysicians recognize that the best way to avoidlegal problems is to be aware of legalrequirements in the jurisdictions in which theypractice, but to think clinically and not legally inthe provision of consistent and sound clinical careto their patients 4. CONFIDENTIALITY ANDMANDATORY REPORTING LAWS 5. CONFIDENTIALITY ANDMANDATORY REPORTING LAWS As early as 430 BC, confidentiality was codified in theHippocratic Oath, Whatever I see or hear,professionally or privately, which ought not to bedivulged, I will keep secret and tell no one. The principle of confidentiality remains an importantethical, legal, and professional practice in clinicalmedicine. The absolute confidentiality of the Hippocratic Oath,however, has given way to several exceptions thatreflect a complex balance between the importance ofprivacy as a necessary component of the doctor-patient relationship that respects patient autonomyand facilitates honest information-sharing fortreatment on the one hand, and the many demands ofan ever more complex society on the other.Specifically, courts and legislatures have determinedthat certain concerns, such as public safety, justifymodification of absolute confidentiality. 6. Examples of situations in which public policyconsiderations limit doctor-patient confidentialityinclude mandated reporting of infectious diseasesand suspected child and elder abuse. States andthe federal government have regulations thatgovern which communicable diseases should bereported to local and state authorities and/or theCenters for Disease Control and Prevention(CDC); this list is revised annually. all states require reporting of internationallyquarantinable diseases (including cholera,plague, and yellow fever) An additional exceptions to confidentiality forpublic safety and welfare considerations. Onesuch area includes the duty to warn or protectthird 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 informationabout the patient, saying that she is his wife. She shows heridentification card verifying this. What should you tell her? 8. you receive a phone call from another physician who is well knownto you in your local community. The physician says that one of yourformer patients has transferred his care to him and he is asking fora 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 deservethe truth and to deny this information to them is to deny an adultsright to the truth. The argument against disclosure is that not alltruth is good to tell, especially to a person who may be harmed byit. In ethical terms, these competing arguments square off as adilemma between respecting the principles of autonomy versusbeneficence. In short, is it better to be honest but risk cruelty. Diagnostic disclosure depends on the capacity of the persons tounderstand and appreciate the diagnosis, their expressed desire toknow what is wrong, and the emotional and moral impacts that thisknowledge may have. Decisions concerning disclosure should alsoaccount for the role of the caregivers and the power they hold overthe 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 personwith a chronic illness, it means knowing what the illness is, whatstage the patient is at, what to expect in the future, and what canbe done to maximize quality of life. In contrast, appreciation describes how well a person recognizeshow facts apply to him- or herself. This ability is distinct from 11. In the case of persons with Alzheimers disease, severalstudies have shown that many persons with mild-stageAlzheimers disease can understand information.Although they may not remember it, when taught, theyare often able to provide a relatively accurate restatementof the facts when asked to summarize what they havelearned. Appreciation is a complex issue in persons withAlzheimers disease. It is often mixed. A patient mayappreciate one feature of the disease, but not another. Inthe case of appreciating Alzheimers disease, there are atleast three features: the diagnosis, the severity, and theprognosis. Studies examining appreciation show thatpatients may appreciate one of these features but not theother. That is, patients may be aware of their diagnosis,but not the severity and prognosis. 12. Steps to Disclose a Diagnosis of Alzheimers Disease Step 1. Assess patients awareness of their cognitiveproblems. Step 2. Assess the degree to which patients arebothered by these problems. Step 3. Assess patients desire to know the cause oftheir memory problems. Step 4. Assess patients understanding of Alzheimersdisease and their desire to know if they have thatdisease. 13. Diagnostic Disclosure You should arrange a joint meeting with theindividual and the family members to disclose thediagnosis. Telling families the diagnosis isAlzheimers can be difficult, since there iscurrently no promising prognosis for thoseaffected. Because the initial meeting can beoverwhelming, you may need to schedule afollow-up meeting to continue discussion of thediagnosis and available support services. After disclosing the diagnosis, expect variousresponses from the individual and family, rangingfrom acceptance of what was suspected andrelief at learning what is causing behavioral 14. Disclosing the diagnosis Consider the following before communicating thediagnosis: Gain an understanding of family dynamics andcultural values. When possible, include all of the professionals(nurses, social workers, psychologists and others )involved in determining the diagnosis in the jointmeeting to answer questions and provide specificrecommendations. Allow sufficient time to answer questions from theindividual and family. A follow-up meeting may need tobe scheduled to continue discussion. Discuss how the disease might progress and agreeupon a specific care plan that considers the personsvalues and beliefs. 15. Covering key issues Alzheimers disease is not a normal part of aging, but adegenerative disease of the brain that results in impairedmemory, thinking and behavior. Alzheimers disease affects every individual differently, so thereis no exact way to determine how the disease will progress. While there is no cure for the disease, some of its symptoms canbe treated by medications and behavioral approaches. Disclosure of the diagnosis allows the individual to maximizequality of life and be involved in planning future care decisions. Assistance is available from the Alzheimers Association andother resources. Progress is being made in research. One way to help thatprogress is by participating in clinical drug studies. To locate theclinical drug studies being conducted in the Throughout the diagnostic evaluation and treatment planning,you should involve the family and caregiver. As the diseaseprogresses and patients become increasingly dependent on theircaregivers, these individuals will become your primary source ofinformation on the patients 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 sufferedfrom memory lapses for several years. They have an outpatient clinicappointment 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 andthe news that his wife has Alzheimers disease was broken to him and thesymptoms were confirmed. Andrew was in the room with 3 strangers who sat looking at him waitingfor his reaction. He was asked whether his wife Joan should be informedof her diagnosis. Andrew asked for advice from the doctor who informedhim that it was ultimately his decision. Andrew decided to call Joan in theclinic room as he thought that Joan was a mature lady and wouldunderstand and adapt to the situation. Andrew felt he could perhaps help her realize that she did have aprogressive memory problem. she was informed of the diagnosis and shesat motionless, disbelieving in the diagnosis.For a while after the diagnosis was disclosed Joan was calm. Shehowever had frequent appointments in the memory clinic with furthertests due to which she began to rebel. Andrew helped her to go to a localday center which worked for a while after which she refused to go.Joan started developing verbally aggressive behavior towards Andrewand he bore the brunt of it. He was hence put in touch with the admiralnurse 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. (Joans autonomy was notrespected and instead the patients 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 clustersof early-onset Alzheimers disease in families For some clusters, where the mutation is known,genetic testing may be helpful in conjunction withcounseling The value of genetic testing is less certain in thecase of apolipoprotein E alleles As long as no intervention has been shown tosignificantly alter the course of dementia, and thepredictive value of the test is low, it does not seemadvisable to recommend genetic testingSlide 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 informedconsent for any medical intervention. Informed consent gave patients the right to choosehow they would be treated. Informed consent is theprocess by which the patient determines whether toaccept or refuse the treatment offered by a physicianor another clinician. The focus is not on the written consent form but onthe process of communication, information exchange,and acceptance or rejection of the medical 21. Themain determination for informed consent isdecisional capacity. Capacity determines whether patients have the abilityto consent to or refuse medical treatment. Psychiatristsare often asked to assess the quality of the patientsdecision making process, often when the patientrefuses a medical intervention recommended bytreating physicians. The legal equivalent of capacity is competency, whichrequires a judicial determination. Under the law, alladults are presumed competent. Competency may be global in certain cases (such asthe case of a patient in a coma). However, capacity andcompetency must be evaluated in the context of aspecific task. Different tasks require different abilities,information, and thresholds of understanding.Therefore, the initial inquiry for a capacity evaluation isthe question, Capacity for what? 22. adequate information for obtaining informed consent: 1. The diagnosis and the nature of the condition beingtreated 2. The reasonably expected benefits from the proposedtreatment 3. The nature and likelihood of the risks involved 4. The inability to precisely predict results of thetreatment 5. The potential irreversibility of the treatment 6. The expected risks, benefits, and results ofalternative, 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 shouldobtain the consent. Beneficence isnt sufficient to eliminate the needfor consent. Decisions made when competent are valid whenconsciousness is lost. 24. Common Challenges to the Practice of InformedConsent Challenge #1. A patient wants information but does notwant 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 tounderstand.Numerical illiteracy (Many people do not understand quantitativeexpressions very well), Numerical indeterminacy (People attach variablemeanings to qualitative expressions of probability such as rarely andlikely.), Biases Challenge #3. Patients may have cognitiveimpairments. 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 populationSlide 26. you inform a patient about the risks and benefits of bone marrowtransplantation for chronic myeloid leukemia. You fully inform thepatient about the risk of transplantation, including the possibility ofdeveloping graft versus host disease. After the transplantation thepatient developed graft versus host disease which is hard tocontrol. The patient learned that there is an alternative treatmentcalled imitanib (gleevec) which does not include the risk of graftversus host disease but which will not cure the leukemia. Thepatient files suit against you. What will be the most likely outcomeof the suit? 27. a man undergoes coronary angioplasty. He is informed that theartery may rupture and that there is a small chance he could bleedto death during the surgery to repair the damaged vessel. He knowshe could have bypass surgery instead. He understands and choosest he angioplasty. He dies from a ruptured blood vessel. The familyfiles suit against you. What will be the most likely outcome? 28. a 40 year-old man is undergoing a nasal polypectomy. In theoperating room you see a lesion on the nasal turbinate that thefrozen section determines to be a cancer, You have found thecancer 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 thechemotherapy. What should you tell her? 30. Advance care planning 31. Advance care planning Elderly patients often have chronic and ultimately fatalillnesses. The patients are often unable to makedecisions. One strategy to make these difficult decisionsis to make them in advance when the patient iscompetent. Advance care planning describes competent patientsdiscussing and then documenting their preferences forfuture medical care. This preserves patients self-determination even after they have lost decision-makingcapacity. The classic mechanism to do this is anadvance directive. 32. An advance directive is a set of instructions indicating a competent persons 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 patients 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 persons 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 directiveat any time. A physician who morally objects to a patients advancedirective may choose not to comply but must facilitatethe patients transfer to another physician.Surrogate decision making In cases of decisional incapacity, the physician maynot dispense with informed consent but instead mustdeal with someone else who acts as a surrogate orproxy on the patients behalf. Surrogate decision makers should use the patientspreferences to the extent that these are known. Usinga patients previously disclosed preferences to makemedical decisions for that patient is called asubstituted judgment 35. in many cases, the patients preferences are unknown,or, because of significant changes in the patients healthand well-being. In these circumstances, the guide forsurrogate decision makers becomes the patients dignityand quality of life. This standard of decision making iscalled the best-interests standard, as the surrogatemust assess the risks and benefits of various treatmentsand alternatives to treatment and choose the one thatbest maximizes the patients quality of life. Patients generally want their surrogate decision makersto use their judgment rather than be bound by thespecifics of living wills. 36. a 75-year-old man arrives at the emergency department febrile,short of breath, and confused. Many family members accompanythe patient, including his wife, his siblings, his children, and hisgrandchildren. The physician wants to perform an emergencylumbar puncture, which the patients wife and siblings are refusing.His 25-year-old granddaughter walks up with a health-care proxyform signed by the patient designating her as the proxy She insiststhat you do the lumbar puncture stating that was herunderstanding of the patients wishes. The rest of the family,including the wife, refuses the lumbar puncture stating that theyknow the patients wishes better. What do you do? 37. 78-year-old woman admitted with metastatic cancerleading to a change in mental status secondary tohypercalcemia. She has a living will in her record thatstates", In the event that I become unable to speak formyself for any reason I wish to express my wish that I notbe intubated or placed on a ventilator under anycircumstances. I also do not wish to receive dialysis .Bloodtesting and Antibiotics are acceptable .What should youdo? 38. End of life issues 39. Refusal of treatment withdrawaland withholding of treatment patients have an ethical and legal right to refuse life-sustaining treatments including artificial nutrition andhydration. Surrogates have a similar right. Some clinicians are comfortable accepting a patients orsurrogates refusal of treatment before it is initiated, yet findthemselves ethically opposed to withdrawing the treatmentafter it is initiated. withholding and withdrawing treatment: withholding is an actof omission, not performing an action, while withdrawing is aninstance of commission, performing an action. Withholding a procedure is often seen as wisely abstainingfrom subjecting the patient to an overly invasive intervention.Conversely, withdrawing a treatment already initiated can givethe 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 patients wishes or best interests, it is the underlying illness that is the cause of death, not the clinicians actions. 41. a 60-year-old man with diabetes and hypertension develops renalinsufficiency to the point of needing dialysis. He is equivocal aboutspending the rest of his life on dialysis, but he agrees to start. Thepatient is not depressed and is fully alert. Six months after startingdialysis, he comes to realize very clearly that he absolutely does notwish to continue. You have no doubt that the patient has fullcapacity to understand the implications of this decision. Whatshould you do? 42. Suicide, andTerminal Sedation The physicians role at the end of life is no longer to cure orcontrol the patients illness but to provide adequate relief ofpain and suffering. Comprehensive palliative care is the standard of care for thedying. This includes adequate pain and symptommanagement, support for the patient and family, and theopportunity to achieve meaningful closure to life. Sometimes patients may ask to die to relieve their suffering.At this point, the clinicians dual obligations of beneficenceand non maleficence come into conflict. Euthanasia is the act of a physician ending the life of apatient having terminal illness or an incurable disease. Thephysician acts directly in bringing about the patients death,such as injecting a lethal dose of drugs. This practice raisesstrong objections. When it is done to a noncompetent patient, 43. Physician-assisted suicide is the act of providing alethal dose of medication to a patient to self-administer.Thus, the physician is a necessary instrument but doesnot actively take part in the ending of the patients life.This practice is currently legal in only a handful ofcountries; in the United States, it is illegal in all statesexcept for Oregon. Terminal sedation is the act of administering high-dosemedication to relieve extremes of pain and suffering. Asthe name implies, the patient is sedated tounconsciousness (sedation), and this practice mayhasten the death of the patient (terminal) by theimpairment of respiratory function. Terminal sedationproperly done is distinct from both assisted suicide andeuthanasia. Medication doses are increased untilsedation 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, ethicallyand legally. Legal liability is a source of concern for manyphysicians, leading some to practice so-called defensivemedicine, characterized by making decisions based inpart or in whole on the desire to avoid legal liability. Whilephysicians should be aware of the requirements ofcompetent care and understand the foundation ofmalpractice liability. Several factors are associated with malpractice riskreduction First, because physicians with poor communication skills are atincreased risk of being sued, improving communication betweenphysician and patient is a key element of risk reduction. Second, acknowledging error and preserving the doctor-patientrelationship 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 areunlikely to provide direct benefit should be offered onlyto patients able to consent, or those with an advancedirective consenting to participate Surrogates can refuse participation or withdraw theperson from participation, even if there is advanceconsent, if the surrogate determines that the protocolis not what the person intended to consent to or is notin the persons best interestSlide 48. ETHICS IN THE NURSING HOME:TREATMENT DECISIONS Studies of attempted resuscitation in nursing homesshow that it is used infrequently and is associated withlow long-term survival Systematic inquiry about advance directives is requiredfor patients in institutions receiving federal funds Regulatory agencies have encouraged enteral feeding innursing homes, but its usefulness is questionable,especially for patients with advanced dementia Enteral feeding is not ethically used as a substitute forhaving staff help patients feed themselvesSlide 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, cliniciansand 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 beineffective The institutions responsibility to protect others mayrequire that it send the patient elsewhereSlide