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.” © CME LLC |
||||||||||
Terms of Service Privacy Advertising
|
||||||||||
