ETHICAL & PRACTICAL ISSUES IN THE ELDERLY Dr. Angela M. Campbell Lourdes Medical Association Conference RCPSG 1 st February 2014
Dec 25, 2015
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 ISSUESHippocratic 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 lifeOffer treatments where possible benefits outweigh any burdens or risksAvoid treatments which will not work , provide no overall benefit or have been refused by a competent patientIf 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 conditionsSeek opinion of relevant specialistCommunicate effectively with patient or relevant others to ensure realistic understanding of expected outcome and benefits , burdens and risks of interventionsIf patient incompetent and there is uncertainty about overall benefit treatment should be started , reviewed and later stopped if ineffective or too burdensomeEthically witholding and withdrawing treatment are the same but the latter is often emotionally more difficult – this should not affect clinical judgementResource 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 routeIn 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
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