Ethical Issues in the Care of Older Persons

Ethics is a fundamental part of geriatrics. Some people would go so far as to describe

geriatrics as end-of-life care.
Issues around medical futility play a central role. The big question, of course, is defining
what is futile. Ageism can play a strong role.
While ethical dilemmas are central to the practice of medicine itself, the dependent nature
of the geriatric patient raises special concerns. Discussions of ethics and aging seem to focus
on the roles of autonomy and rationing.
In many instances, the former may be used as basis for the latter. Ironically, the greatest
ethical attention is focused on the group who are least able to express a preference: those in
some form of vegetative state.

AUTONOMY AND BENEFICENCE
Two principal components to ethical discussions are the concepts of autonomy and
beneficence.
Autonomy refers to ones right to control ones destiny, that is, to exert ones will.
Obviously there are limits to how freely such control can be expressed, but for geriatric
purposes the principal issue revolves around whether the patient is able to assess the
situation and make a rational decision independently.
Beneficence refers to the duty to do good for others, to help them directly and in avoiding
harm.
This idea comes very close to paternalism, where one becomes the agent of another in order
to make decisions as a father might do for a child. Such action directly conflicts with the
principle of autonomy.

MAJOR ETHICAL PRINCIPLES
Beneficence - The obligation to do good
Nonmaleficence-The obligation to avoid harm
Autonomy- Duty to respect persons and their right to independent self-determination
regarding the course of their lives and issues concerning the integrity of their bodies and
minds
Justice
Nondiscrimination: duty to treat individuals fairly; not to discriminate on the basis of
irrelevant characteristics
Distribution: duty to distribute resources fairly

Fidelity
Duty to keep promises
Physicians face a difficult set of choices in practice when they seek to walk these often fine
lines. As Meier and Cassel (1986) note:
Although the medical community has frequently been attacked for its paternalistic attitude
toward patients, it is usually conceded that paternalism can be justified if certain criteria are
met: if the dangers averted or benefits gained for the person outweigh the loss of autonomy
resulting from the intervention; if the person is too ill to choose freely; and if other persons
in similar circumstances would likely choose the same intervention.
COMPETENCE AND INFORMED CONSENT
In the case of elderly persons, much of the concern is directed toward the issue of
understanding and expressing opinions. The two most extreme cases are the comatose
patient, who clearly cannot communicate, and the aphasic patient, who may be unable to
communicate effectively.
In the former case, we must look for other ways to preserve autonomy. In the latter, we
must be very careful to assess and separate areas of communication from reasoning.
There is an important difference between the concepts of competence and decision-making
capability. The former is a legal term that refers to a persons 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 them.
In the case of dementia, persons may or may not be capable of understanding and
interpreting complex situations and of making a rational decision. Intellectual deficits are
spotty. A person may get lost easily or forget things but still be able to make decisions.
Determining cognitive ability and decision-making capacity is not easy. One must distinguish
memory from understanding. Physicians judgments about patients capacity to consent
were much better for cognitively intact patients than for mildly demented patients.
To make a rational decision, we all need a clear sense of the alternatives, including their
benefits and risks. Ideally, a person making a care decision would have complete information
about the full range of options and the risks and benefits associated with each option.
Rarely are patients given the full description of the benefits and risks. In some instances, this
is appropriate, because the entire list of all possible risks may be excessive and a discussion
of very serious yet very rare conditions may inappropriately frighten a patient.

ADVANCE DIRECTIVES AND END-OF-LIFE CARE
One way of trying to deal with the situation when the patient cannot express a preference is
to encourage the development of advance directives, in which persons indicate what they
want done under such circumstances.
Federal law requires that all persons entering a hospital or a nursing home be offered the
opportunity to indicate advance directives

AREAS OF GENERAL AGREEMENT AMONG PATIENTS, PHYSICIANS AND FAMILY MEMBERS ABOUT
END-OF-LIFE CARE
Be kept clean
Name a decision maker
Have a nurse with whom one feels comfortable
Know what to expect about ones physical condition
Have someone who will listen
Maintain ones dignity-LIFE CARE
Trust ones physician
Have financial affairs in order
Be free of pain
Maintain a sense of humor
Say goodbye to important people
Be free of shortness of breath
Be free of anxiety
Have physician with whom one can discuss fears
Resolve unfinished business with family or friends
Have physical touch
Know that ones physician is comfortable talking about death and dying
Have physician who knows one as a whole person
Share time with close friends
Believe family is prepared for ones death
Feel prepared to die
Presence of family
Being mentally aware
Not being a burden to family or society
Be able to help others
Feel ones life is complete
Be at peace with God
Have funeral arrangements planned
Treatment preferences in writing
Not die alone
Remember personal accomplishments
Receive care from personal physician