Ethical Issues in the Care of the Elderly
by Leslie Knowlton
| Geriatric Times |
 |
March/April 2002 |
|
Vol. III |
|
Issue 2 |
Ethical issues in health care particularly affect the elderly for several
reasons: older people are sick more often than younger people, suffer more from
being in the end stage of various chronic progressive degenerative diseases and
are most likely to lack the capacity to make critical decisions when such
decisions have to be made, Kenneth Prager, M.D., told attendees during the
one-day “Cardiovascular Issues in Geriatrics” conference held in
May at Columbia Presbyterian Medical Center. His lecture, “The Age-Old
Question: Ethical Issues in the Care of the Elderly,” was the keynote
speech.
Before the conference began, Prager, who is clinical professor of medicine,
director of clinical ethics and chairman of the medical ethics committee at
Columbia Presbyterian Medical Center, told Geriatric Times that the fact
he was asked to speak on this topic at such a gathering shows the importance
ascribed by all medical subspecialties to end-of-life care, including wishes
and instructions.
“These issues are important in all fields of medicine and get us down
to a final common pathway,” he said. “The bottom line is what do we
all do when someone is gravely ill and facing critical choices.”
Prager reviewed the four principles of medical ethics, beginning with the
principle of beneficence and non-maleficence, which “basically means do
good and don’t do bad,” he said.
The second principle is that of autonomy: patients with the capacity to make
health care decisions should have the right to make decisions about their own
bodies, whether or not those decisions are approved of by their physicians or
families.
The third principle is the notion of justice, which Prager described as a
broader societal issue concerning the allocation of limited health care
resources. “It’s not something physicians deal with in day-to-day
interactions with patients, but nevertheless very important,” he said.
The fourth principle is respect for the sanctity of human life.
“I think this is something in our marrow, in our bones...It is there
as the all-pervasive theme...and probably comes from our religious
tradition[s].”
These four principles pose special considerations for the elderly, Prager
said. Regarding beneficence and non-maleficence, he explained that calculating
a cost-benefit analysis of medical treatment for older patients is much more
difficult than calculating such an analysis for younger patients.
“Cost-benefit considerations in the elderly are generally more subtle
and more complex, as harm is more likely and benefit is less certain,” he
said. “It’s much easier to consider radical major surgery on a
vibrant 35-year-old person than someone who is an octogenarian.”
Such considerations also enter into questions of whether to hospitalize an
elderly patient. Prager explained, “They get confused in the hospital,
there’s disruption of their daily routine, [and] they may fall. So while
on paper it looks like it’s the right thing to do to put them in
hospital, you don’t approach this decision the same way you would with a
younger patient.” He added that these considerations make decisions about
outpatient treatment for the elderly more complicated.
“If you have a patient with malignancy, should this person have
chemotherapy? And even with prophylactic therapy, such as with coumadin
[Warfarin], for example, you worry about the patient falling or getting mixed
up because of doses.”
Returning to the issue of decisions about surgery for elderly patients,
Prager stressed that physicians need to carefully weigh the cost-benefit ratio
and discuss it with the patient. He gave an example of a man who was given a
knee replacement operation and was allowed to die at his wife’s request,
not because the knee operation was unsuccessful, but because he developed a
pulmonary complication that would have compromised his quality of life to an
intolerable degree.
“So before elective surgery, discuss what are the goals of surgery,
what is the literature on the likelihood of success?” instructed Prager.
“We have an ethical responsibility to know this ourselves and spend
enough time with our patients…so they will make an informed
decision.”
Regarding the principle of autonomy, Prager said a doctor has a duty to
facilitate its expression by a patient.
“This is not just something we can take for granted,” he said.
“We have to enable our patients to exercise autonomy in a meaningful way.
How can a patient make a decision and exercise autonomy about that decision if
you, the physician, have not adequately informed them about the risks involved
and the likelihood of problems before the [medical intervention]?”
Prager next discussed vehicles that patients have for expressing autonomy in
case they lose their capacity to make decisions. One option is written advance
directives, in which a person of “sound mind and feeling reasonably
well” details how they would like to be treated under various
circumstances if and when their own capacity is lost. “I personally am
not crazy [about advance directives],” Prager said. “I think the
problem with them is that although they are vehicle[s] for expressing these
wishes at a time when things are going well, they sometimes bind surrogates or
proxies into a corner by the language that they have in a way that the patient
may not have meant. Once you have something down in writing, it’s in
writing and you have to respect it, but then you have to start thinking of the
situation [at hand] and what did they mean by this word and so on.”
The second way a patient can exercise their autonomy ahead of time is by
designating a health care proxy, which Prager said was “probably the best
answer, although it’s not extensively used.”
He explained that in New York state, a health care proxy law was passed in
1991 to give people the right to designate, when of sound mind, the agent who
will make all necessary decisions, including withdrawal of life support if they
lose mental capacity. The proxy can also give the agent the power to withdraw
nutrition and hydration if specifically mentioned.
Prager said that the proxy gives the agent a tremendous amount of power and
makes the job of the medical ethics committee a lot easier. Even though the
proxy law has been in effect for a decade, however, it is estimated that only
10% of the population have filled out proxy forms, he reported.
A third vehicle by which incapacitated patients can exercise autonomy is
through physicians accepting from witnesses “previously stated clear and
convincing evidence stated verbally” by the patient. “Clear and
convincing evidence is a very high standard,” Prager said.
“It’s not just someone looking at an episode of ‘ER’
and saying ‘I don’t want to be like that if I get
sick.’”
As with advance directives, state the clear and convincing evidentiary
standard in New York is based on case law. Specifically, it is based on a case
in which the courts held that if doctors had clear and convincing verbal
evidence that the patient did not want a feeding tube, it could be removed.
“So it’s important for you as a physician in these situations to
speak to relatives, surrogates, friends and ask if [the patient] has ever
spoken about their wishes,” said Prager.
Another factor that interferes with patient autonomy is today’s
managed care industry. “The HMO situation [interferes] by cutting down on
the amount of time that many physicians spend with their patients discussing
these issues,” Prager said. “I think we are putting a barrier to
exercise autonomy by virtue of interfering with informed consent.” And
while the role of an ethics committee is very helpful in trying to
“ferret out” what some of the issues in these difficult end-of-life
decisions are, the better the physician does their own job, the less need there
is to call for an ethics consult, Prager explained.
Still, the ethics committee is sometimes aware of certain laws, policies and
procedures that the physician might not know and can serve in an advisory and
educational capacity, he added. The risk of having an ethics committee, he
cautioned, is that physicians can get lazy.
“They can say ‘if I ever run into problems, I’ll just call
the ethics committee and let them deal with end-of-life issues.’ And
that’s not good, because when I come to see a patient--never having seen
that patient before and having no relationship whatsoever with the
patient’s family--I am not nearly in as good a position as a doctor who
has had a long-standing relationship with that patient to really discuss these
sensitive issues. So I think that the ethics committee can be abused, called
upon to take over the work and save some time for the busy and harried
physician. I think that’s an unfortunate thing.”
Prager next discussed the principle of justice as it applies to the elderly.
“How do you approach giving health care with limited budgets?” he
asked. “There are two opposing sides, the strictly utilitarian ethical
viewpoint and then there’s the idealistic.”
The utilitarian viewpoint says that health care resources should be
allocated to do the most good for largest number of people. “Now that
sounds great, except for some of the possible offshoots of that
principle,” said Prager, referring to the Medicaid portion of the Oregon
Health Plan, which he said calls for allocating resources where they will be
most likely to be successful, where the good result will be the most prolonged
and where they will help the most people.
“Now it’s clear that this may really impact negatively on older
people in terms of health care delivery. This is because the success of
interventions is less in the elderly, the length of time the intervention will
last is going to be less and, in most areas, the elderly don’t constitute
the largest bulk of population.”
Another way that rationing can be detrimental to the aged is that it affects
women more than men, Prager said. That is because above age 65, for every 68
men there are 100 women. And over age 85, there are 48 men for every 100
women.
“Any strictly utilitarian approach to allocating resources based on
age is going to willy-nilly have an effect that will be disproportionally felt
by women.”
Prager next explained that the idealistic approach to justice says,
“No, we’re not going to allocate our resources solely based on
where there’s the most bang for the buck. We should give help to people
who need it the most.”
But with this approach, the elderly will disproportionally need more health
care dollars than younger people, he added.
“I think that...we vacillate between the two poles. We want to get a
little bit of this, a little bit of that. And perhaps there is a golden way,
perhaps there is a way to not totally disenfranchise older people and not
totally do something using all our health care resources without thinking of
the usefulness in terms of prolonged effect for the greatest number of people.
I don’t have an answer to it. I point out the justice aspect simply to
ferment thought.”
Prager said that the issue of physician-assisted suicide is a collision
between the principle of autonomy and the principle of respect for sanctity of
human life. “We recoil from [physician-assisted suicide] because we feel
there’s something wrong with assisting to take a life,” he said.
“There is that red line that you refrain from crossing, doing nothing to
purposefully speed the death of a patient...At least that’s certainly how
I feel now.”
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