ETHICAL & PRACTICAL ISSUES
IN THE ELDERLY
Dr. Angela M. Campbell
Lourdes Medical Association Conference
RCPSG 1st February 2014
WHAT IS GERIATRIC MEDICINE ?
“ Geriatric Medicine is a whole person specialty. Based on
a solid infrastructure of general medicine , it involves
consideration of psychological , social and spiritual
dimensions , together with functional and environmental
assessments. A Geriatrician needs to be aware of legal
aspects – capacity and consent , human rights ,
guardianship ; and ethical conundrums , such as when to
investigate or treat ”
Prof. G. Mulley : A career in Geriatric Medicine ( BGS Newsletter August 2007 )
THE ELDERLY IN SOCIETY
Demographic changes - the very elderly, over 85s , are the
fastest growing section of society
Health economic implications – increasing need and cost
of health and social care for the frail elderly population
Changing role of the elderly in society – contribution and
quality of life
PRINCIPLES OF MEDICAL ETHICS
Autonomy – authentic “ self-determination ” influenced
by information given , cognition , mood , and personal
versus societal values
Justice – “ fair ” allocation of health and social care
resources based on need and without discrimination
Beneficence – “ do good ”
Non-maleficence – “ do no harm ”
ETHICAL CHALLENGES IN GERIATRIC MEDICINE
Witholding and withdrawing treatment e.g. enteral
nutrition , CPR
Consent and mental capacity
Advanced directives
Euthanasia ( “ a good death ” )
WHAT IS MENTAL CAPACITY ?
An adult is “ capable ” if he or she has :
Received information to make a decision
Is not under pressure from someone else
Can communicate the decision
Consistently holds to this decision
WHAT IS MENTAL INCAPACITY ?
An adult is “ incapable ”if he or she :
Cannot act or make decisions or communicate decisions or
understand decisions or retain memory of the decision because of mental disorder or inability to communicate
Not all or none
May be capable of certain types of decisions but not others
AWISA ( 2000 ) & MENTAL CAPACITY ACT
( 2005 ) - GENERAL PRINCIPLES
Benefit the adult
Take account of adult`s past and present wishes
Take account of views of relevant others
Use the least restrictive power possible
Adult must be encouraged to use existing skills
AREAS COVERED
Decisions about a) money and property b) health and
welfare c) both
Intervention order - covers single issue e.g. property sale
Guardianship order - covers long-term needs e.g. in
dementia
GUARDIANSHIP
2 doctors` reports confirming incapacity
Mental Health Officer report ( if welfare )
Relevant adult ( if financial only )
Granted by a sheriff and registered by the Public Guardian
Usually for 3 years but may be indefinite
CURRENT USE
Many elderly in institutional care are incapable –
certificate and treatment plan reviewed annually ( now
every 3 years if established incapacity )
Emergency treatment exempt but must consult proxy for
other interventions e.g. elective surgery , enteral nutrition ,
antibiotics
Proxy decision makers may be formal welfare guardian or
informal e.g. NOK
GUIDANCE ON ETHICAL ISSUES
Hippocratic Oath e.g. “ no intentional killing by act or
omission ”
Professional bodies e.g. BMA, GMC , BGS
“ Decisions relating to cardiopulmonary resuscitation : a
joint statement ” BMA , Resuscitation Council ( UK ) ,
RCN ( 2007 )
“ Treatment and care towards the end of life : good
practice in decision making ” GMC ( 2010 )
Theological guidance e.g. CTS 2010
GMC GUIDANCE : END OF LIFE CARE
“ Good end of life care helps patients with life-limiting
conditions to live as well as possible until they die , and to
die with dignity ”
End of life conditions – progressive conditions , organ or
systems failure , acute catastrophic events , PVS
Most difficult decisions are often around starting or
stopping potentially life-prolonging treatments – benefit
versus burden of care
GMC GUIDANCE : ETHICAL PRINCIPLES
Based on Human Rights Act ( 1998 )
Presumption in favour of prolonging life
Offer treatments where possible benefits outweigh any
burdens or risks
Avoid treatments which will not work , provide no overall
benefit or have been refused by a competent patient
If patient incompetent must consult Welfare POA /
Guardian / Advocate , healthcare team and take into
account e.g. advance directive
GMC GUIDANCE : CLINICAL JUDGEMENT
Refer to relevant clinical guidelines for specific conditions
Seek opinion of relevant specialist
Communicate effectively with patient or relevant others to
ensure realistic understanding of expected outcome and
benefits , burdens and risks of interventions
If patient incompetent and there is uncertainty about
overall benefit treatment should be started , reviewed and
later stopped if ineffective or too burdensome
Ethically witholding and withdrawing treatment are the
same but the latter is often emotionally more difficult –
this should not affect clinical judgement
Resource constraints may be an issue
GMC GUIDANCE :CLINICALLYASSISTED
NUTRITION & HYDRATION ( 1 )
Need to assess patient`s nutritional and hydration status
and ensure that this is optimised where possible via the
oral route
In patients unable to maintain adequate nutrition and
hydration status orally options include IV or S/C fluids ,
NG , or RIG / PEG feeding
“ The current evidence about the benefits and burdens of
these techniques in treating and managing patients towards
the end of life is not clear cut ”
ENTERAL FEEDING
ACUTE STROKE
Dysphagia common but
usually resolves within a
month
Severe stroke and
persistent dysphagia has
high mortality
PEG / RIG superior to NG
DEMENTIA
Dysphagia versus food
refusal
Mortality at 1 year 87% (
in stroke 56% )
Meta-analysis showed no
significant benefit
GMC GUIDANCE : CLINICALLY-ASSISTED
NUTRITION & HYDRATION ( 2 )
If these might prolong a patient`s life then treatment
should be offered
“ Where a patient`s death is not imminent but their
condition is severe and the prognosis very poor you may
consider that clinically-assisted nutrition and hydration ,
while likely to prolong their life , will cause them suffering
which could be intolerable ”
“ You must seek a second or expert opinion from a senior
clinician……..You should also consider seeking legal
advice ”
EUTHANASIA “ A GOOD DEATH ”
Killing is murder and assisting suicide a criminal offence
A competent patient can refuse treatment
Treatment of an incompetent patient should be in their best
interest.This may be by witholding burdensome treatment
or providing palliative treatment that could shorten life – “
doctrine of double effect ”
“ Burden ” of care versus sanctity of life
“ Slippery slope ” - a right to die or a duty to die ?
LIVERPOOL CARE PATHWAY
LIVERPOOL CARE PATHWAY
ICP designed to manage the care of a person in the last
days or hours of life - facilitates MDT communication /
documentation
Criteria for use – possible reversible causes for current
condition have been considered ; MDT agreed that patient
is dying ; 2 of following apply : bedbound , semi-comatose
, unable to take sips of fluid , no longer able to take tablets
LCP – ANTICIPATORY PRESCRIBING
Pain – Morphine
Nausea – Levomepromazine
Agitation – Midazolam
Excess respiratory secretions – Hyoscine butylbromide
LCP - CONTROVERSY
Care or neglect ?
“ Pathway to death ”
Hospice vs acute hospital setting
Diagnosis of “ dying ”
Ethical principles
Training & audit
10 KEY LCP MESSAGES
LCP is only as good as those who use it
LCP should not be used without education & training
Good communication is pivotal to success
LCP neither hastens nor postpones death
Diagnosis of dying should be made by the MDT
LCP does not recommend use of deep continuous sedation
LCP does not preclude “ artificial ” hydration
LCP supports continual reassessment
Reflect , audit , measure & learn
Stop , think , assess , change
NEUBERGER REPORT ON THE LCP “ MORE CARE
LESS PATHWAY ” JULY 2013
Nutrition & hydration in the last days and hours of
life
Recognising the uncertainty of the diagnosis of
dying
Communication with patients and families and
between staff
INTERIM GUIDANCE :CARING FOR PEOPLE IN THE LAST
DAYS & HOURS OF LIFE ( KEY PRINCIPLES )
NHS SCOTLAND DECEMBER 2013
Communication
MDT discussion and decision making
Address physical , psychological , social and spiritual
needs
Consider needs of relatives and carers
ISSUES ON PILGRIMAGE TO LOURDES
Elderly – assess co-morbidities , function and cognition , capacity ,
polypharmacy and medication administration
Management of symptoms – prior to travel on pilgrimage seek advice
/ care plan from local Palliative care team
Consider and discuss potential impact of journey and pilgrimage on
symptoms
Clarify insight of pilgrim and their relatives on prognosis and establish
if there is an ACP
Insurance cover - implications of change / deterioration in condition
and of hospitalisation in France