Ethical Issues in Geriatric care Flashcards
What is the Fiduciary Role of PAs?
PAs & patient have a fiduciary relationship
■ Characterized by:
– Unequal power
■ PA (& Physician)
– Knowledge, skills, attitudes & values necessary in medicine
■ Patient
– Generally does not possess these sufficient to help
themselves
– Places trust in the PA to do the right thing for the patient
■ Patient interests come first (…where have I heard that before)
Core Biomedical Ethics
- Respect for the autonomy of patients
- Beneficence
- Non-maleficence
- Justice
Paternalistic Model
-Provider informs the patient with
authority
-Patient will ultimately be thankful
-Provider acts as the patient’s
guardian
-Provider determines what the
patient values (or should)
-Patient autonomy → patient
assent, either now or later, to what
the provider determines
“Whatever you say Doc”
Informative Model
-Scientific or Consumer model
-Provider gives the patient all
relevant information
-Patient learns all relevant medical
knowledge & makes decisions
-Patient determines what is best for
them
-Provider is a technical expert
-No role for provider’s values
-Patient autonomy → complete
control over decision making
Interpretive Model
-Provider discerns patient’s values
& helps patient make choices
-Provider helps patient realize their
values
-Provider neither dictates nor
judges patient values
-Provider helps patient understand
how to use their values in the
situation
-Provider is a counselor
Deliberative Model
-Provider helps patient select best
values for the clinical situation
-Provider elaborates on medical
information & values
-Provider & patient deliberate on
values patient could & should
pursue
-Provider offers moral persuasion
without coercion
-Provider is a teacher & a friend
Goals of Ethical Care
Respect the autonomy of the patients, minimize harms & maximize benefits
1. Help them understand their medical condition & it’s natural course
2. Help them understand the proposed treatment & it’s benefits & risks
3. Help them understand their alternative choices & their benefits & risks
4. Help them predict the outcomes of their choices
Autonomy & Beneficence
■ Autonomy assumes patient capability & competence
■ Clinicians acting on the best interests of older patients sometimes choose a paternalistic approach
______ — a person’s ability to act reasonably after understanding
the nature of the situation being faced
Competence
Determining cognitive ability & decision-making capacity
- Understanding: the ability to comprehend the disclosed information about the nature of the situation/medical problem
- Appreciation: grasping the significance of the disclosed information for their situation
- Reasoning: the ability to engage in a reasoning process about the risks & benefits of a procedure or treatment
- Choice: ability to choose whether or not to undergo further testing or treatment
de facto incompetent
Incompetence → proven in court (cumbersome & expensive)
■ Psychiatric consultation is often employed by providers to verify a lack of
decision-making ability suspected by the primary care provider
– When confirmed, patients are often referred to as de facto
incompetent (in fact incompetent , but not legally determined)
– These patients cannot exercise the right to choose or refuse
treatment, & require another individual-de facto surrogate-to make
decisions on their behalf
T/F In the absence of a health care proxy the provider has a duty to locate a
reasonable surrogate to act on behalf of the patient
T
De facto Surrogate
■ Decisions made by surrogates are guided by substituted judgment
– Based on the known wishes of the patient explicitly written or
stated
– If no formal wishes were written or stated the surrogate makes
decisions on knowledge they have about the values & preferences
of the patient
– If the surrogate does not know the wishes or values of the patient
treatment decisions are based on what any reasonable person
would select under the prevailing circumstances given the existing
knowledge & available options
Advance Directives
A legal document allowing patients to convey their decisions about
what type of care they want to receive in the event that they are
unable to express their wishes.
Living will
■ Specifies care preferences at the end of life
– Limited — generally addresses:
■ Specific clinical situations (vegetative states or terminal illness)
■ A few treatment options (ie CPR, intubation, artificial food &
hydration, dialysis, or IVs)
Durable Power of Attorney (DPA)
■ Living wills cannot anticipate every circumstance
■ DPA allows a surrogate/proxy to act on the patients behalf when they
are unable to express a preference
– DPA specifies who & under what circumstances a proxy can
exercise authority
Timing of advanced directives
■ The Federal Patient Self Determination Act requires that all persons
entering a hospital or a nursing home be offered the opportunity to
indicate ADs.
– Is this the best time?
■ Ideally, the patient’s provider has previously discussed establishing an
AD with the patient &/or proxy, & all have given due process to the
development of appropriate documents
Physician/Medical Orders for Life-
Sustaining Treatment (P/MOLST
– Serve as a medical order in
addition to your advance
directive
– Make it possible to provide
guidance healthcare
professionals can act on
immediately in an emergency
The right of patients to refuse medical therapy limited by 4 counter state interests:
- Preservation of life
- Prevention of suicide
- Protection of third parties (eg children)
- Preserving integrity of the medical profession
Legal Aspects of Palliative & EOL Care
■ Mentally competent patients need not be terminally ill to exercise this right to refuse interventions, they have the
right regardless of health status.
■ The right applies equally to withholding proposed treatment & to discontinue initiated treatments
Physician-Assisted Death (PAD)
■ Physician’s act of providing medication, a prescription, information, or other interventions to a patient with the
understanding the patient intends to use them to
commit suicide.
■ Legal in Colorado, Oregon, Washington State, D.C,
Vermont, & California, Hawaii & Montana
■ Become familiar with the state laws where you end up
working
Medical interventions that can be stopped
■ Every medical intervention, including artificial nutrition & hydration, may be terminated at the pts request.
■ Specific legal cases have sanctioned the withholding or withdrawal of respirators, chemotherapy, blood transfusions, hemodialysis & major surgical operations
Decision-Making Capacity
■ Competent pts have the exclusive right to refuse medical care, even if in conflict with family
■ Living wills or more broadly called advanced directives
left by dying individuals are also definitive.
■ Competence must be determined by a judge, relates to
whether individuals have the legal right to make their
own decisions & whether others should respect the
decisions they make
Palliative Sedation
■ Measure of last resort at the end of life to relieve severe & refractory symptoms
It is the administration of sedative medications, in monitored settings, to decrease state of awareness or unconsciousness
■ Intent is to relieve intolerable suffering for terminally ill pts in such a manner as to preserve the moral
sensibilities of the pt, the medical professional, & family/friends
CHANGES TO CAUSE OF DEATH
■ If additional medical information or autopsy findings become available that would change the cause of death originally reported, the original death certificate should be amended by the certifying physician by immediately reporting the revised cause of death to the State Vital Records Office.
