Module 3: Legal & Ethical Issues

Question 1

Geriatric Vs. Pediatrics

-Similarities

Answer 1

1. Issues take on special form
   - Consent
   - Substitute decision making
2. Paternalism — Be careful not to take decision capacity away from elderly when capacity remains

Question 2

Guiding Principles of Medical Ethics

Answer 2

1. Respect for autonomy
2. Nonmaleficence “Do no harm”
3. Beneficence “benefits vs burdens — “Do the most good”
4. Justice — Right to be treated equally and equal access to healthcare

Question 3

Justice

-Info

Answer 3

1. “Life cases should be treated alike”
2. Consider heterogeneity of the elderly — one elderly patient might be completely independent while another is not
3. Caution while using chronological age**

Question 4

Decisional Capacity Vs. Competence

Answer 4

1. A physician or NP may evaluate a patients capacity to make decision — CLINICAL Decision
2. Competence and incompetence are LEGAL terms — They imply that a court has taken a specific action**

Question 5

Competence Definition

Answer 5

1. A LEGAL estimation that recognizes that persons beyond a certain age (18) generally have the cognitive ability to negotiate certain legal tasks, such as entering into a contract or making a will
2. Incompetence only decided by a court of law
3. REQUIRED functional assessment of person’s abilities and disabilities

Question 6

Decisional Capacity

Answer 6

1. A CLINICAL determination of a patient’s ability to make decisions about treatment interventions or other health related matters
   —Ex: An elderly patient with delirium or an infection loses capacity for a LIMITED amount of time
2. Partial capacity — making decisions during times of lucidity
3. TIME-limited and situational-specific

Question 7

Elements of Capacity to make a Medical Decision

-Components?

Answer 7

1. Ability to UNDERSTAND
   - disease process
   - proposed therapy & alternative therapies
   - Advantages, AE’s, and potential complications of each therapy
   - Possible course of the disease w/out intervention
2. Ability to communicate a decision

Question 8

Elements of Capacity to make Financial Decisions

Answer 8

1. Ability to manage bill payments

2. Ability to appropriately calculate and monitor funds

Question 9

Elements of Capacity to Make a Last Will and Testament

Answer 9

1. Ability to identify the individuals involved
2. Ability to remember estate plans
3. Ability to express the logic behind choices

Question 10

Standardized Tests of Decisional Capacity

Answer 10

1. Mini-Mental Status Exam (limited Utility)
2. Executive Interview 25-item exam (EXIT 25) of executive function
3. Capacity to consent to treatment instrument

Question 11

Hierarchy of Strategies for Surrogate Decision Making

Answer 11

Hierarchy from bottom (Foundation) to top

1. Use the principle of beneficence
2. Use substituted judgement
3. Respect the patient’s last indication of their wishes during a period in which they have capacity

Question 12

Last Indication of Wishes

Answer 12

1. Most relevant when patient can foresee incapacitation
2. Detailed advance directives important
3. As long as the circumstances remain substantially as predicted, other persons should NOT be allowed to reverse these decisions

Question 13

Substituted Judgement

Answer 13

1. The process of constructing what the person would have wanted if he/she had been able to foresee the circumstances and give direction
2. DPOA for health affairs
3. A person granted DPOA takes precedence over the next of kin, but not over the patient’s prior wishes

Question 14

Principle of Beneficence

Answer 14

1. The decision maker weighs the benefits and burdens of treatment for the patient
2. Analysis is best done by someone who knows the patient well:
   - What gives that patient pleasure?
   - What causes agitation, fear, pain, or discomfort?
   - How the patient reacts to a change in setting, use of restraints, and similar matters

Question 15

Conservators/Guardians

Answer 15

1. Appointed by a court in the absence of next of kin or durable power of attorney
2. Two Different conservar types**
   - Conservator of finance
   - Conservator of person

Question 16

Surrogacy

Answer 16

1. Pt report surrogate decision maker to supervision HCP
2. Can be identified by supervision HCP — Ex: Next of Kin
3. No eligible surrogate available?? — A physician can be an appointed surrogate after consulting w/ ethics committee**
   - MD must obtain concurrence from a second MD that is not involved in the patient’s care.
4. MD Surrogate is LIMITED and CANNOT make a decision to withdraw or withhold any artificial hydration or nutrition

Question 17

Temporary Loss of Decisional Capacity

Answer 17

1. Surrogate decision maker should err on the side of more aggressive interventions if:
   - The patient’s wishes are not known
   - Circumstances are substantively different from what the patient anticipated

Question 18

Decisions Near End of Life

-Refusing Treatment

Answer 18

1. The right to refuse treatment has been confirmed by the US Supreme Court
2. Refusal can occur before/after the intervention started
3. No ethical or legal distinction is made between declining to initiate therapy and discontinuing therapy

Question 19

Decisions Near End of Life

-The rule of Double Effect

Answer 19

1. May be two effects of palliative interventions
   - The intended effect of relieving discomfort or suffering
   - The unintended effect of hastening death
2. Aggressive pain management, when respiratory depression is foreseeable but not intended, IS considered ethical

Question 20

Decisions Near End of Life

-Predicting Prognosis

Answer 20

1. Clinician judgement and prediction rules but inaccurate

2. Instruments such as APACHE III are unable to address the burden of treatment or the patient’s quality of life

Question 21

Special Issues in Dementia

-Truth Telling

Answer 21

1. Patients w/ dementia should be given a chance to understand what is happening to them.

Question 22

Special Issues in Dementia

-Autonomy

Answer 22

1. Inability to perceive cognitive decline and need for help
   - Unable to understand rationale for needing assistance (Help at home, sitter services, day services)
2. The NP plays a crucial role in helping ensure patient safety

Question 23

Special Issues in Dementia

-Advanced Directives

Answer 23

Conflict can arise between patient’s previous directives and what is NOW best for the patient

Question 24

Ethics in Long Term Care

Answer 24

1. Self Neglect
   - Patients have malnutrition and weight loss
   - Depression
   - Standardized care — Lack of acknowledging patients’ personhood
2. Regulatory barriers - Highly regulated

Question 25

Long-term care Ombudsman

Answer 25

1. Go into nursing homes and serve as advocates for people who live in the nursing homes

Question 26

Elder Mistreatment

Answer 26

1. When there is a relationship or a reasonable expectation of a trusting relationship — A trusted other who is mistreating

Question 27

Abuse in Stages of Dementia

Answer 27

1. Early dementia — Financial abuse
2. Middle stage — Physical abuse
3. Late stage — Neglect

Question 28

AIM Domains

Answer 28

1. The older adult
2. The trusted other
3. Context of their situation