The clinical practice of geriatric medicine can be ethically complex :
1. Many elderly people face chronic illnesses for which treatment is costly and risky and outcomes are uncertain
2. Many elderly have conditions which profoundly impair communication and cognition. There may be uncertainty about who should make health care decisions and what constitutes informed consent
3. The elderly account for a larger segment of spending on health care leading to questions about the relative value of marginally effective treatments when survival is not likely to be long
Advance directives/medical power of attorney/living wills/do-not-resuscitate orders:
Individuals can provide documentation about how they want decisions made about future medical care – what is to be done and/or what is not to be done. They generally specify what medical action should be taken if the writer is mentally incompetent or has a terminal illness.
• legislation between different jurisdictions varies
• there can be considerable anguish about initiating directives
• legal and ethical obligations of health professionals to comply or not comply
• potential consequences to the health professional of not complying
• role of courts in over riding documentation
• competence of person/how authentic where their wishes
• who should initiate discussion about preparing documentation (patient, family, lawyer or physician?) – samples/proforma’s are generally available
End of life decisions:
Advances in technology have increased the ability to keep the human body biologically alive, but has resulted in a number of ethical issues regarding the right to die, the costs associated with such technology, and the quality of life on artificial life support. Health professionals and families face ethical and moral dilemmas when making decisions as to under which circumstances should attempts to prolong life be stopped. The decision can be more difficult in the absence of knowing the patients wishes (eg advance directives), but the participation of close family members can aid the process. The courts and legislatures are being increasingly asked to be involved in these highly personal and private decisions.
Use of physical and pharmacological restraints:
Restraints are potentially a form of elder abuse and have been the subject of media and regulatory scrutiny. They are indicated if the patients are a danger to themselves after other forms of behaviour management have been exhausted, but are often considered an unjustified infringement on patient autonomy. Physical restraints (arm and leg cuffs; lap belts; chairs with locking trays; bedding materials; side rails on bed) can be used to prevent falls and wandering, but can create problems (decrease feeling’s of self worth, loss of dignity, increased frustration and anger; increased risk for injury, skin lesions). Chemical or pharmacological restraints (eg psychoactive drugs) must be of clear benefit to the patient. Restraints should not be used as a form of punishment or for the convenience of health professionals. If restraints are used, there needs to be clear documentation of the rationale for their use and they should be used under clear consensus based guidelines.
When resources are limited or scarce, rationing is the denial of beneficial health care. Rationing health care based on age has probably always been implicit, but given the demographic and economical issues facing society it is now an important issue for public debate.
There are philosophical arguments for rationing based on age that have been debated and rebuttals provided . Arguments for rationing based on age usually appeal to society’s duty to the younger generations or on utilitarian grounds (investing health care dollars in younger persons represents a better return). Critics of age based rationing point out that in a just society, health care should meet the needs of all, regardless of age and that society has special obligations to older persons.