Ethical Issues in Geriatric
Medical Care
James F. Bresnahan, S.J., J.D.,
Ph.D.
The Patient/Physician Relationship
The fragility of aging patients often presents special challenges
to caregivers because it aggravates the power differential between
patient and caregiver. As the power gap between the patient's
and the caregiver's capacities for thinking and deciding widens,
the effort to bridge the gap, to assist the patient to participate
in planning and receiving care, must increase.
Thus, caregivers of the aging are challenged to strike an appropriate
balance between caregiver "beneficence" (acting in the
patient's best interests) and patient "autonomy" (defining
what one's own best interests really are). Caregiver beneficence
has to include protecting a fragile patient's autonomy and working
to evoke what this patient really wants by medical caregivers--not
what these caregivers expect or want the patient to want from
them, or what involved family members may want and express emphatically
to caregivers. Other important ethical values are fidelity, justice
and non-maleficence.
Practical considerations
for the caregiver
- Judging patient's possibly
varying mental capacity to participate effectively in decisions
about medical care-even if the patient has been judged by a court
to be incompetent for other matters and placed under legal guardianship.
- Forging a real "therapeutic
alliance" with a fragile patient--avoiding subtle coercion,
but also encouraging hesitantly expressed but real patient wishes
and desires.
- Renewing constantly one's
valuing of aging patients with all of their eccentricities and
vulnerabilities, so as to avoid inadvertent or deliberate infantilizing
of these persons.
- Giving careful attention to
the risk/benefit ratio in proposed diagnostic or therapeutic
interventions as the caregiver comes to believe the particular
patient has difficulty seeing it, or would see it if more capable
of participating.
- Giving primacy to a competent
aging patient's own participation over family interference, yet
also recognizing beneficent family interventions made on behalf
of patients with diminished competence.
- Being sensitive to signs of
elder abuse that can occur within family settings, whether physical,
psychological or financial, and being ready to evaluate elder
abuse with the help of the interdisciplinary team and to report
it to appropriate authorities.
- Evaluating carefully the ongoing
use of any physical or chemical "restraints" (often
too easily employed) whether in hospital or in nursing care facilities.
- Giving support to free and
informed participation of aging persons in clinical research
trials potentially beneficial to all who are aging by discussing
present or future participation in such investigations and recording
patient attitudes and wishes, and what kinds of participation
they might authorize for a future time when they become incompetent
to consent (probably legal authority for the patient to employ
this kind of "advance directive" will be needed).
Areas of special concern for
patients, families and health care professionals faced with worsening
chronic illness and especially at the time of approaching death:
- For most aging persons, attending
to preserving or enhancing the aging patient's physical and psychological
function and comfort (i.e., quality of life) as a chronic disease
develops is quite often of concern which is at least equal to
patient concern to have medical efforts aimed at fending off
death (i.e., quantity of life).
- Timely and tactful raising
of the question of whether the patient has yet prepared an "advance
directive" (a "living will" or, the better alternative
in Illinois, "the health care agency") giving direction
about the kinds of cure-oriented treatments one would not want
begun or continued--should a patient in the future become unable
to give these instructions. It is appropriate to mention hospice
care and palliative medicine as affirmative alternatives to cure-oriented
treatment, since this removes the possible mistaken interpretation
that an advance directive means consenting to the caregivers
"giving up" on a dying patient.
- Giving explicit and timely
attention to medical orders implementing comfort, physical or
mental. (Developing a care plan that meets comfort needs and
assuring that a DNR order does not interdict any therapy that
might provide comfort, e.g., local radiation to painful metastases.)
- Reviewing the goals of any
artificial feeding programs in light of total care plans and
impact of depriving the conscious patient of a major source of
enjoyment of life (oral intake). Artificial feeding (as opposed
to helping a patient eat by chewing and swallowing) need not
be considered morally obligatory--but may be considered an excessively
burdensome medical treatment which a patient may not want and
is not in any way a requirement of good care in many circumstances.
- Understanding the function
and invoking in timely fashion the provisions of the Illinois
"Surrogate Health Care Decision-making Act" which provides
for identifying a decision maker and determining what kinds of
medical care a patient would not want as death approaches--for
the patient who has not made a formal written advance directive.
- Taking account of growing
conflict of interest ethical predicaments: "Cost considerations"
and "quality control" demands urged by third party
payers or others are normally appropriate only insofar as one
has good reason to believe one's patient would want caregivers
to follow these. Advocacy for one's patient is a more urgent
responsibility as managed care programs become more intrusive
and capitation creates a new conflict of interest for the caregiver.
Third parties/payers should not be allowed to interfere with
physicians advising patients on the available and most appropriate
options for care.
Indications for consultation
When a course of action is not clear to caregivers because of
value conflicts, they can seek informal advice from senior staff,
or from the Geriatrics Services, or from hospital General Counsel.
The resource for formal ethics advice is the Hospital Ethics Committee,
which is designated to be available to all involved parties to
consult about such issues (and the Chair of which can, when appropriate,
enter a note about the ethics consult on the patient's hospital
chart).