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Ethics is a fundamental part of geriatric care as it involves issues of medical futility, autonomy, and rationing of treatment for dependent elderly patients. Two main ethical principles are autonomy, which is the right to make one's own medical decisions, and beneficence, which is the duty to help others. However, beneficence can conflict with autonomy if it involves paternalistic decision making for patients. Determining an elderly patient's competence and decision making capacity can also be difficult due to cognitive impairments.
Ethics is a fundamental part of geriatric care as it involves issues of medical futility, autonomy, and rationing of treatment for dependent elderly patients. Two main ethical principles are autonomy, which is the right to make one's own medical decisions, and beneficence, which is the duty to help others. However, beneficence can conflict with autonomy if it involves paternalistic decision making for patients. Determining an elderly patient's competence and decision making capacity can also be difficult due to cognitive impairments.
Ethics is a fundamental part of geriatric care as it involves issues of medical futility, autonomy, and rationing of treatment for dependent elderly patients. Two main ethical principles are autonomy, which is the right to make one's own medical decisions, and beneficence, which is the duty to help others. However, beneficence can conflict with autonomy if it involves paternalistic decision making for patients. Determining an elderly patient's competence and decision making capacity can also be difficult due to cognitive impairments.
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