ETHICAL

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ETHICAL PRACTICAL ISSUES IN THE ELDERLY

• Dr. Angela M. Campbell
• Lourdes Medical Association Conference
• RCPSG 1st February 2014

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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 )
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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

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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

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ETHICAL CHALLENGES IN GERIATRIC MEDICINE

• Witholding and withdrawing treatment e.g.
  enteral nutrition , CPR
• Consent and mental capacity
• Advanced directives
• Euthanasia ( a good death )

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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

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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

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AWISA ( 2000 ) MENTAL CAPACITY ACT ( 2005 ) -
GENERAL PRINCIPLES

• Benefit the adult
• Take account of adults 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

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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

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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

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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

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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

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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

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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

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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

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GMC GUIDANCE CLINICALLYASSISTED NUTRITION
HYDRATION ( 1 )

• Need to assess patients 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

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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

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GMC GUIDANCE CLINICALLY-ASSISTED NUTRITION
HYDRATION ( 2 )

• If these might prolong a patients life then
  treatment should be offered
• Where a patients 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

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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 ?

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LIVERPOOL CARE PATHWAY
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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

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LCP ANTICIPATORY PRESCRIBING

• Pain Morphine
• Nausea Levomepromazine
• Agitation Midazolam
• Excess respiratory secretions Hyoscine
  butylbromide

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LCP - CONTROVERSY

• Care or neglect ?
• Pathway to death
• Hospice vs acute hospital setting
• Diagnosis of dying
• Ethical principles
• Training audit

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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

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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

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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

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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