Ethical Issues of Elder Care

Objectives Apply the concept of decision-specific capacity to older adults. Apply the concept of decision-specific capacity to older adults. Apply legal and ethical principles in the analysis of complex issues related to care of older adults: informed consent, refusal of treatment, and advance directives Apply legal and ethical principles in the analysis of complex issues related to care of older adults: informed consent, refusal of treatment, and advance directives Define ethics, bioethics, ethical dilemma, and nursing ethics. Define ethics, bioethics, ethical dilemma, and nursing ethics.

Objectives Describe the major ethical principles that have an impact on older adults’ health care. Describe the major ethical principles that have an impact on older adults’ health care. Discuss the difference between personal values and professional codes of ethics. Discuss the difference between personal values and professional codes of ethics. Apply a decision-making model to an ethical dilemma in nursing practice. Apply a decision-making model to an ethical dilemma in nursing practice.

Decision-making Capacity Implies the ability to understand the nature and consequences of different options, make a choice among those options, and communicate that choice. Implies the ability to understand the nature and consequences of different options, make a choice among those options, and communicate that choice. Clinicians assess decision-making capacity. Clinicians assess decision-making capacity. Required to give informed consent Required to give informed consent May fluctuate over time from transient changes in ability to comprehend and communicate May fluctuate over time from transient changes in ability to comprehend and communicate

Decision-making Capacity Competency. Legal determination by a judge as to mental disability or incapacity; whether a person is legally fit and qualified to give testimony or execute legal documents. Competency. Legal determination by a judge as to mental disability or incapacity; whether a person is legally fit and qualified to give testimony or execute legal documents. The law presumes that all adults are competent and have decision-making capacity to make health care decisions. The law presumes that all adults are competent and have decision-making capacity to make health care decisions.

Decision-making Capacity Decision-specific capacity vs. global decisional capacity Decision-specific capacity vs. global decisional capacity May fluctuate over time May fluctuate over time Cognitive impairment  automatic incapacity Cognitive impairment  automatic incapacity No “gold standard” for capacity determination No “gold standard” for capacity determination

Verification of Decision-making Capacity Required when a person is refusing or giving consent for treatment and/or executing an advance directive Required when a person is refusing or giving consent for treatment and/or executing an advance directive Ability to voice a choice or preference Ability to voice a choice or preference Adequate disclosure Adequate disclosure Understanding of information: recall information; manipulate information; appreciate situation Understanding of information: recall information; manipulate information; appreciate situation Voluntary consent Voluntary consent Consistency Consistency

Informed Consent Can make a choice Can make a choice Understand and appreciate the issues Understand and appreciate the issues Rationally manipulate information Rationally manipulate information Make a stable and coherent decision Make a stable and coherent decision Age-related factors: Age-related factors: Hearing and visual impairments Hearing and visual impairments Impaired communication: written and verbal Impaired communication: written and verbal Values and beliefs Values and beliefs Fluctuating or diminished decision-making capacity Fluctuating or diminished decision-making capacity

Refusal of Treatment The right to refuse treatment even if refusal hastens or results in their death. The right to refuse treatment even if refusal hastens or results in their death. Requisite capacity must be determined: Requisite capacity must be determined: Can make a choice Can make a choice Understand and appreciate the issues Understand and appreciate the issues Rationally manipulate information Rationally manipulate information Make a stable and coherent decision Make a stable and coherent decision

Advance Directive (AD) Patient Self-Determination Act (PSDA) mandates: 1. Provide all adult patients with written information concerning care decisions 2. Ask patients whether they have an AD 3. Maintain policies re: discussions of AD 4. Honor AD 5. Educate patients about AD 6. Conduct community education 7. Do not discriminate

Advance Directives Living Will Living Will Durable Power of Attorney for Health Care (DPOAHC) or Health Care Proxy (HCP) Durable Power of Attorney for Health Care (DPOAHC) or Health Care Proxy (HCP) Guardian; conservator; proxy; health care agent Guardian; conservator; proxy; health care agent Advance Health Care Directive Advance Health Care Directive

Ethics Terminology Ethics: declarations of right or wrong and what out to be Ethics: declarations of right or wrong and what out to be Bioethics: application of ethics to matters of life and death Bioethics: application of ethics to matters of life and death Ethical dilemma: a difficult problem seemingly incapable of a satisfactory solution; situation involving two equally unsatisfactory alternatives Ethical dilemma: a difficult problem seemingly incapable of a satisfactory solution; situation involving two equally unsatisfactory alternatives Nursing ethics: application of ethical principles in nursing practice Nursing ethics: application of ethical principles in nursing practice

Major Ethical Principles Autonomy Autonomy Justice Justice Beneficence Beneficence Nonmaleficence Nonmaleficence Veracity Veracity Substituted Judgment Standard Substituted Judgment Standard Best Interest Standard Best Interest Standard

Ethical Principles Autonomy – right to self-determination, independence, and freedom. Autonomy – right to self-determination, independence, and freedom. Justice – obligation to fair to all people Justice – obligation to fair to all people Beneficence – duty to act for the benefit of others; “doing good” theory Beneficence – duty to act for the benefit of others; “doing good” theory

Ethical Principles Nonmaleficence – do no harm; protect patient from harm if they cannot protect themselves Nonmaleficence – do no harm; protect patient from harm if they cannot protect themselves Patient abandonment Patient abandonment Personal relationships with patient Personal relationships with patient Impaired practice Impaired practice Veracity – honest and trustworthy in dealing with people. Veracity – honest and trustworthy in dealing with people.

Ethical Principles Substituted Judgment Standard – surrogate decision-maker Substituted Judgment Standard – surrogate decision-maker Best Interest Standard – decision based on what health care providers and/or families decide is best for that person. Best Interest Standard – decision based on what health care providers and/or families decide is best for that person.

Values and Codes of Ethics Personal Values Personal Values Professional Values Professional Values Code of Ethics Code of Ethics

Ethical Dilemmas Decision-making Model Collect, analyze, and interpret the data Collect, analyze, and interpret the data State the dilemma State the dilemma Consider the choices of action Consider the choices of action Analyze advantages and disadvantages of each course of action Analyze advantages and disadvantages of each course of action Make the decision Make the decision Evaluate the effectiveness of the decision Evaluate the effectiveness of the decision

Summary Concept of decision-specific capacity Concept of decision-specific capacity Verification of decision-making capacity Verification of decision-making capacity Informed consent Informed consent Refusal of treatment Refusal of treatment Advance directives Advance directives Ethics, bioethics, ethical dilemmas, nursing ethics Ethics, bioethics, ethical dilemmas, nursing ethics Seven major ethical principles; decision-making model for ethical dilemmas Seven major ethical principles; decision-making model for ethical dilemmas

Questions?