Ethical/Legal Issues in Care of

Geriatric Patients

Geriatric Patients in General

Do distinct issues arise when caring for the
elderly?
Issues such as informed consent
E.g. patients with Alzheimer's

Can generalities about geriatric patients be easily

drawn ?
Are all 90 year olds senile

Ethical Principles
The Four Principles
Autonomy/Respect
Beneficence
Non-maleficence
Justice

Respect for
Persons/Autono
my

Acknowledge a persons right to make choices, to

hold views, and to take actions based on personal
values and beliefs

Justice

Treat others equitably.

Nonmaleficence
(do no harm)

Obligation not to inflict harm intentionally;

Beneficence (do
good)

Provide benefits to persons and contribute to their

welfare. Refers to an action done for the benefit of
others.

Veracity

To be honest and trustworthy in their dealings with

people

Respect for Persons/Autonomy

Professionals have a duty to treat the patient according to the
patient's desires, within the bounds of accepted treatment, and to
protect the patient's confidentiality
Primary obligations include involving the patient in treatment
decisions in a meaningful way, with due consideration being
given to the patient's needs, desires and abilities, and
safeguarding the patient's privacy
Nurses may interfere only when they believe a person does not
have sufficient information or capacity to understand, or is being
coerced.

Justice
Justice is the least discussed principle,
but relevant here.
like cases should be treated alike
chronological age alone should never be a
consideration in whether a particular
treatment is recommended

Nonmaleficence
This principle expresses the concept
that professionals have a duty to protect
the patient from harm.
This principle requires that health-care
providers protect those patients from
harm if they cannot protect themselves

Beneficence
Good care requires that the health-care provider
understand the patient from a holistic perspective that
includes the patients beliefs, feelings, and wishes as
well as those of the patients family and significant
others
Beneficence is the motivating force behind caring;
however, beneficence is complex because it is
difficult to determine what exactly is good for another
and who can make the decisions about what is good.

Veracity
The professionals primary obligations include
respecting the position of trust inherent in the
physician-patient, nurse-patient, and other healthcare
provider-patient relationships, communicating truthfully
and without deception, and maintaining intellectual
integrity.
Veracity or truthfulness requires that health-care
providers not intentionally deceive or mislead patients .

Different Inputs
Having said this, it is sometimes the case that we face
different inputs when dealing with geriatric patients
E.g., Different likely outcomes of surgery
Greater focus on pain relief

When this is true, it is clearly of ethical relevance,

however we should be very careful about assuming this
is true in a particular case
E.g., Would you give the transplant to the 70 year old or the
20 year old? Too simple

Creeping Paternalism
A central issue in dealing with geriatric
patients is what we might call creeping
paternalism
Creeping because it sometimes operates unsaid

Tendency to assume that geriatric patients

are not fully capable of making their own
decisions

Paternalism
Generally shows up in
Relaxed standards re. confidentiality (with
family members)
Increased willingness to seek consent from
others
Increased willingness to treat patient as
incompetent

Competence/Capacity
Terms competence and decision-making
capacity generally refer to this same issue
Except as defined in legislation, these terms
may be used interchangeably

Competence/Capacity
Competence has tended in the past to be
considered in an all-or-none sense:
i.e., the idea of a person being declared
incompetent and losing rights re finances,
property, voting, health care decisions, etc.

Competence/Capacity
Approach to competence must be a functional one,
determined by a persons ability to understand, retain
and assess information in order to make a choice and
then communicate that choice
In the health care context, it is the ability to
understand information relevant to a health care
decision and to appreciate the reasonably foreseeable
consequences of a decision (or lack of decision)

Competence/Capacity Ethical Importance

Competent patients are, by definition, able to give informed
consent to treatment
The importance of informed consent is supported both by
the principle of autonomy - respect for persons requires
respecting their informed decisions
the principles of beneficence/non-maleficence generally, an informed patient is a good judge of what
broad sort of treatment is in his/her best interest

Competence/Capacity Legal Significance

In law, competent patients are entitled to
make their own informed decisions

If a patient is incapable, physician must

obtain consent from a substitute decision
maker

Choosing Substitute Decision

Maker (SDM)

Where a health care professional has patient

who requires health care but lacks
competency to make health care decision;
must make reasonable attempt to determine
whether patient has substitute decision
maker who is available
Emergency exception - consent not required
where health care necessary to preserve life
or health and delay in finding SDM may pose
significant risk to patient

Choosing Substitute Decision

Maker (SDM)
Hierarchical list of substitute decision-makers if one
not appointed, or appointed person is
unable/unwilling to act
next of kin
last on list is the health care professional
responsible for the proposed health care

Choosing Substitute Decision Maker

(SDM)
SDM must act in accordance with:
(a) directions

of the health care provider

(b) the wishes of the patient as expressed to SDM when
competent; or
(c) what the SDM believes to be the best interests of
patient

SDM entitled to information necessary to make

informed decision

Choosing Substitute Decision

Maker (SDM)

Where doctor determines patient not

competent to make health care decision:

must document it in chart and

Ensure SDM is aware of right to contest
finding
protection from liability for health care
professional and SDM if acting in good
faith

Points to Remember
As long as a person retains decision-making capacity,
his or her wishes and decisions shall govern health
care
A persons capacity to make health-care decisions is
usually self-evident. On the other hand, in advanced
old age, and in the face of dementia, it is often unclear
as to whether a person is capable of making specific
health-care decisions for him- or herself
Cognitive impairment does not automatically constitute
incapacity. For example an older adult may be declared
incompetent in one domain such as in handling
financial matters, but may retain the ability to make
medical decisions.

Age-related changes influence or may impede the

process of informed consent for older adults:

Sensory deficits in hearing and vision

Impaired ability to ask a question

Both written and verbal information must be

presented appropriately with opportunities to repeat

and clarify content
Values and beliefs about making health-care choices

(i.e., let the doctor decide)

Decision-making capacity that fluctuates or is

diminished.

Neglect
Not commonly used piece of legislation
Definition neglected adult
incapable of caring properly for him/herself
because of physical or mental infirmity,
not receiving proper care and attention,
refuses, delays or is unable to make provision for
proper care for self, and
is not suitable for treatment under Mental Health
Act

Dealing with Neglect

Reporting to social worker or Director who
conducts an investigation
Application to judge for declaration of
neglected adult
If finding made, judge may direct placement
of individual

Other Issues
A Living Will provides specific instructions about
the particular kinds of treatments / interventions
an individual would or would not want to prolong
or sustain life.
Living Wills are generally used to declare
wishes, to refuse, limit, or to withhold life
sustaining treatment under certain
circumstances should the individual lose
capacity and become unable to communicate.

Power of Attorney

Power of Attorney - an individual designated, and

who is presumably known and trusted by the patient,
to make health-care decisions for them should they
lose decision-making capacity.
The agent or surrogate can interpret the individuals
wishes as medical circumstances change.
A surrogate, one who makes decisions on behalf of
another who is unable to make decisions for him- or
herself, can be designated either informally or
formally.

Mental Health
Mental Health Act
deals with involuntary detention and treatment of
persons with mental disorders (disease or
disability of the mind) who require hospitalization
in the interests of their own safety, safety of others
(or safety to property)
certificates signed by physicians

 Questions