Ethics and Care of Elderly

Question 1

What did Raymond Tallis (geriatrician) believe that ‘CARE OF THE ELDERLY’ entailed?

Answer 1

Older people are endlessly fascinating

because they have 70 years of experience coiled up inside them

Question 2

What key issues should be considered with older people?

Answer 2

• more deferential to the doctor
• have impaired or fluctuating capacity
• higher dependance on family/social care
• diverse and complex healthcare needs (risk and polypharmacy)
• may be discriminated against (conscious/unconscious)
• Equality ACT

Question 3

What characteristics are included within the EQUALITY ACT?

Answer 3

• age
• sexuality
• gender reassignment
• disability
• sex
• marriage and civil partnership
• race
• religion or belief
• pregnancy and maternity

cannot be discriminated against on these grounds

Question 4

What key attribute should be established with any patient, particularly in the elderly?

Answer 4

CAPACITY

assessing capacity must be done in terms of the mental capacity act 2005

Question 5

What legislation governs capacity?

Answer 5

Mental Capacity Act 2005

=> gives statutory validity to advanced statements for power of attorney on behalf of individuals lacking capacity

Question 6

What criteria must be met in order for an adult to have CAPACITY?

Answer 6

[according to the MCA 2005, so these are legal criteria]

• understands the info relevant the decision
• retain the info
• use or weigh that info as part of the process of making the decision

OR

• communicate their decision

Question 7

How is CAPACITY a DYNAMIC concept?

Answer 7

• Capacity may change over time
• patients may be capacitous at some times and for some choices but not others
• be wary of placing too much emphasis on former assessments
• consider environment, demeanour and manner when assessing for capacity
• doctors have big influence in this

Question 8

What implementations may be made if a patient LACKS CAPACITY?

Answer 8

• Lasting Power of Attorney (LPA)
• valid advance decision statement (AD)
• if no valid LPA or AD, act in patient’s best interests
• anyone who can advocate for patient?
• DOCUMENT all assessments and rationale for conclusions/decisions

Question 9

What are the legal considerations for capacity in elderly care?

Answer 9

• FORCED treatment is rare
• Common Law: right to refuse Rx even if it may result in death
• MCA 2005: allows for ‘deprivation of liberty’ applications
• often made in respect of people with dementia as ‘informal’ patients

Question 10

What changes can dementia cause (affecting capacity)?

Answer 10

• cognitive deficit
• behavioural/personality changes
• temporary or permanent incapacity

other considerations:

• change in personhood?
• pre-morbid decision making value?
• value of person?
• screening for dementia ?

Question 11

What MLE model is used to approach autonomy?

Answer 11

4-principles model

set out by:
- right to SELF-DETERMINATION is a right of life for all human beings

• infringements on autonomy COMPROMISE the TRUST in which the doctor-patient relationship is built
• PATERNALISM is out-dated and morally dubious for practising healthcare

Question 12

What is PATERNALISM?

Answer 12

old-fashioned model for healthcare

=> doctors making decisions for patient w/o involving their wishes

Question 13

What reasons have been made for using (JUDICIOUS) PATERNALISM?
i.e. utilised out of legal need

Answer 13

• Autonomy must be informed to have value
• autonomy may not be as highly valued for patients as it is for doctors/ethicists
• emotions, confusion, pain and distress may compromise decision-making even in an adult with capacity (so that is only partially autonomous)
• autonomous decision-making may result in poor and preventable outcomes

Question 14

What considerations should be made for QUALITY OF LIFE in older patients?

Answer 14

• how can QoL be assessed?
  (adjusted disability life years, ADLs are not an equivalent parameter)
• QoL for pt with cognitive impairment?
• ethics demands that decisions for non-treatment should be based on best interests not chronological age
• age discrimination vs right to life

Question 15

What issues arise with elderly care in COVID-19?

Answer 15

• elderly patients are disproportionately affected
  (esp. in care homes)
• many are vulnerable and are shielding
• access to Rx may therefore be limited
• CEILINGS of care present in the elderly populations
• Ordinary vs Extraordinary Rx decisions
• Advance Care Plan - decisions ahead of time