B

ecause of public health measures and advances in medicine, people are living longer. However, the elderly population is uniquely burdened with illnesses. An elderly person has, on average, 3 to 4 chronic illnesses and a nearly 20% annual risk of hospitalization. The elderly population accounts for most deaths. Also, many older persons have impaired decision- making capacity and insufficient social support and economic resources. Therefore, clinicians likely will care for an increasing number of elderly patients with challenging medical and psychosocial problems that, in turn, may precipitate daunting ethical dilemmas. Because of these factors, clinicians should be familiar with the ethical dilemmas commonly encountered when caring for elderly patients. 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. And 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

ETHICAL PRINCIPLES
Clinical ethics is the identification, analysis, and resolution of moral problems that arise in the care of patients. Four widely accepted prima facie principles that characterize the ethical concerns of clinical practice are autonomy, beneficence, non-maleficence, and justice. Autonomy Beneficence Non-maleficence Justice it refers to the duty to respect persons and their rights of self-determination it refers to the duty to do good it refers to the duty to prevent or do no harm it refers to the duty to treat individuals fairly (free of bias and based on medical need)

When caring for elderly individuals, clinicians may find these ethical principles at odds with each other. For example, respect for patient autonomy may be at odds with a clinicians desire to do good or prevent harm.
Ethical and Medico-legal in Geriatric Patients 1

COMMON ETHICAL DILEMMAS IN GERIATRICS

Informed Consent: The voluntary choice of a competent patient.
Respect for patient autonomy is the ethical principle that underlies informed consent. For patients to be autonomous when making health care decisions, clinicians must adequately inform them about their illnesses and treatment options. The basic requirements of informed consent are that the physician conveys the necessary information to the patient (ie, the nature of the illness, the proposed intervention, and the risks and benefits of and alternatives to the proposed intervention) and has confirmation of the patients

decision- making capacity, understanding of the information, and voluntary agreement to the intervention. Informed consent should be obtained for most interventions. However, in certain circumstances, informed consent cannot be obtained. For example, when a patient lacks decisionmaking capacity, consent must be obtained from a surrogate. In emergencies, consent is presumed when an advance directive (AD) or a surrogate is unavailable. It is ethically and legally permissible for patients with decision-making capacity to refuse unwanted medical interventions. Physicians have a duty to respect these decisions. Not surprisingly, a patients refusal of an intervention may be at odds with a clinicians desire to do good. Although refusal of an intervention may be regarded by the clinician as wrong, it is not necessarily irrational. If the clinician determines that the patient is adequately informed about the proposed intervention and the risks of refusing it (informed refusal), the patients decision should be respected. 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. Alternatives to the proposed intervention 7. The expected risks, benefits, and results of alternative, or no, treatment

Patient 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. Confidentiality of information includes the patients history, assessment findings and the treatment rendered. The ethical principle of autonomy requires clinicians to maintain patient confidentiality. To be autonomous, patients must be able to control personal information. Furthermore, maintaining confidentiality is necessary for the proper evaluation and treatment of patients. However, statutory and case law duties may obligate clinicians to breach confidentiality to serve the best interests of others (eg, society). For example, most states have mandatory reporting laws for infectious and communicable diseases, as well as the suspected child and elder abuse. States and the federal government have regulations that govern which communicable diseases should be reported to local and state authorities and/or the Centers for Disease Control and Prevention (CDC); this list is revised annually.

Ethical and Medico-legal in Geriatric Patients

Diagnostic Disclosure: It is the argument that patients deserve the truth and to deny this
information to them is to deny an adults right to the truth. The argument against disclosure is that not all truth is good to tell, especially to a person who may be harmed by it. In ethical terms, these competing arguments square off as a dilemma between respecting the principles of autonomy versus beneficence. In short, is it better to be honest but risk cruelty. Diagnostic disclosure depends on the capacity of the persons to understand and appreciate the diagnosis, their expressed desire to know what is wrong, and the emotional and moral impacts that this knowledge may have. Decisions concerning disclosure should also account for the role of the caregivers and the power they hold over the patients. One critical step in living with an illness is to understand 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 ones sense of self.

Determining Decision-Making Capacity: Clinicians commonly care for elderly persons who have
conditions that impair decision-making capacity. However, patients must have decision-making capacity to be autonomous and participate in informed consent. Decision-making capacity includes the ability to communicate a choice, understand the nature and consequences of the choice, manipulate rationally the information necessary to make the choice, and reason consistently with previously expressed values and goals. The level of decision-making capacity should be in accordance with the risks and benefits of the decision to be made. For example, the physician should be absolutely certain that a patient who refuses a low-risk, yet life-saving, intervention has adequate decision-making capacity. At times, determining a patients decision-making capacity can be difficult, especially if the patient or family disagree on the assessment, the patient has concerns unfamiliar to the clinician (eg, spiritual concerns), or the patient has a psychiatric illness that is difficult to treat. Colleagues who can help determine a patients decision-making capacity include psychiatrists, geriatric specialists, chaplains, social workers, and ethics consultants. The clinician has a duty to protect patients without decision-making capacity from inappropriate health care decisions. In such cases, the clinician is not overriding patient autonomy because autonomous decisions by the patient are not possible. In these circumstances, clinicians should identify an appropriate surrogate decision maker.

Ethical and Medico-legal in Geriatric Patients

Advance Care Planning: Allows a patient to identify health care preferences and surrogate
decision makers in the event the patient cannot make health care decisions In emergencies, consent is presumed, and cliniciansshould endeavor to preserve life; however, most clinical situations are not emergencies. Clinical situations that involve patients who lack decisionmaking capacity require ways to facilitate decision making. Elderly patients often have chronic and ultimately fatal illnesses. The patients are often unable to make decisions. One strategy to make these difficult decisions is to make them in advance when the patient is competent. Advance care planning describes competent patients discussing and then documenting their preferences for future medical care. This preserves patients self-determination even after they have lost decision-making capacity. The classic mechanism to do this is an advance directive. 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 A document describing a patients preferences for the initiation, continuation, or discontinuation of particular forms of treatment. b. 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 statement 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. Also, a physician who morally objects to a patients advance directive may choose not to comply but must facilitate the patients transfer to another physician.
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When and How Surrogates Should Be Used for Decision Making : When a patient
lacks decision-making capacity, the clinician must rely on a surrogate to make decisions for the patient. When a patient lacks decision-making capacity, the clinician must rely on a surrogate to make decisions for the patient. If the patient has an AD that identifies a surrogate, this choice should be respected. However, many patients without decision-making capacity do not have an AD. In these circumstances, clinicians must identify an appropriate surrogate. The ideal surrogate is one who best understands the patients health care values and goals. Family members usually serve as surrogates; however, some states specify a hierarchy of surrogates (eg, court-appointed guardian, spouse, next of kin). In some cases, a patients family and other interested persons may agree that a close friend may be the most appropriate surrogate.

END OF LIFE ISSUES

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. Withholding is an act of omission, not performing an action, while withdrawing is an instance of commission, performing an action. Some clinicians are comfortable accepting a patients or surrogates refusal of treatment before it is initiated, yet find themselves ethically opposed to withdrawing the treatment after it is initiated. 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 patients death and can be regarded as an act of abandonment. 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.

Euthanasia, Physician-Assisted Suicide, and Terminal Sedation: The physicians role at the
end of life is no longer to cure or control the patients 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 clinicians dual obligations of beneficence and non-maleficence come into conflict.

Ethical and Medico-legal in Geriatric Patients

a. Euthanasia It 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 patients death, such as injecting a lethal dose of drugs. This practice raises strong objections. When it is done to a non-competent patient, it can be called murder. Euthanasia is currently illegal throughout the United States. b. Physician-assisted suicide It is the act of providing a lethal dose of medication to a patient to selfadminister. Thus, the physician is a necessary instrument but does not actively take part in the ending of the patients 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. c. Terminal sedation It is the act of administering high-dose medication to relieve extremes of pain and suffering. As the name implies, the patient is sedated to unconsciousness (sedation), and this practice may hasten the death of the patient (terminal) by the impairment of respiratory function. Terminal sedation properly done is distinct from both assisted suicide and euthanasia. Medication doses are increased until sedation occurs (along with the possible risk of the hastening of death) only if non-sedating doses do not achieve pain relief.

Use of Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders:

In practice, consent to CPR is presumed, and clinicians must perform CPR unless a do-not-resuscitate order (to which the patient or surrogate has consented) exists. Adjusting for severity of illness, do-not-resuscitate order rates increase with age. However, most elderly persons do not have an accurate understanding of what is meant by CPR, and most have not discussed CPR with their clinicians. Furthermore, patients overestimate the success of CPR. However, after being informed of the actual efficacy of CPR, many elderly persons decline the procedure. Also, studies have found that surrogates and clinicians often incorrectly predict elderly persons preferences for CPR. Furthermore, clinicians cannot infer an elderly patients desire for CPR on the basis of whether the patient has an AD. These studies emphasize the need for clinicians to explicitly discuss CPR and its efficacy with their elderly patients.

Ethics in the Nursing Home:

Most nursing home residents are elderly, poor, physically disabled, and cognitively impaired, and many have experienced losses of social support. Autonomy of nursing home residents may be limited by government regulations, restrictions on activities, and congregate living. That is why, the quality of care and sufficiency of staffing in nursing

Ethical and Medico-legal in Geriatric Patients

homes long has been of concern. Not surprisingly, many seriously ill people would rather die than live in a nursing home. Nevertheless, safety is a frequently cited reason for offering nursing home care. The ethical dilemma of autonomy versus safety commonly affects nursing home residents. For example, the clinician regards the benefits of nursing home care (eg, safety and skilled nursing care) as greater than the harms (eg, limited autonomy). If discharging the patient to her home is clearly dangerous, then the clinician has an ethical and possibly a legal duty (eg, vulnerable adult statute) to protect the patient with appropriate institutional care. If the risk of harm is ambiguous, then discharging the patient to her home with appropriate monitoring on a trial basis could be attempted and may be necessary for the patients acceptance of future nursing home care. For nursing home residents, clinicians should endeavour to maximize autonomy while ensuring the patients (and others) safety. Maximizing autonomy can be achieved, in part, by respecting the residents values and goals and involving them in the decisions (eg, treatments, personal care, communications). When feasible, requests for privacy should be honored. Physical restraints should be avoided, not only because they severely restrict autonomy but also because they cause more harm than good

CONCLUSION
It is reasonable to expect that clinicians will care for an increasing number of elderly persons with challenging medical and psychosocial problems. These problems and issues may lead to daunting ethical dilemmas. We reviewed ethical dilemmas commonly encountered when caring for elderly persons but recognize that this group is by no means exhaustive. Many ethical dilemmas arise because of inadequate patient- clinician communication. Effective communication is not only a clinicians duty; it is an important feature of the art of medicine and may prevent many ethical dilemmas. Nevertheless, even in the best of circumstances, ethical dilemmas occur. A useful approach to ethical dilemmas begins with a review of the medical indications, patient preferences, quality of life, and contextual features of a given case. This approach enables clinicians to identify and analyze the relevant facts of a case, define the ethical problem, and suggest a solution.

REFERENCES
Ethical Issues in Geriatrics: A Guide for Clinicians By: PAUL S. MUELLER, MD; C. CHRISTOPHER HOOK, MD; AND KEVIN C. FLEMING, MD Medico-legal and Ethical Issues In Geriatric Care Dr. DOHA RASHEEDY ALY

Ethical and Medico-legal in Geriatric Patients