Slide Number 1Ethical Issues in Health Care for Older PersonsLet’s Think About…Basic Principles of Ethical Decision MakingAutonomyAutonomyOther PrinciplesRealize…CaseCaseAdvance DirectivesProblems with Advance DirectivesProblems with Advance DirectivesSUPPORT StudyEthics at the End of LifeEthical Issues at EOL - EuthanasiaResearch EthicsHealth Care RationingCopyright 2007, The Johns Hopkins University and Bruce Leff. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed.This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this site.Ethical Issues in Health Care for Older PersonsBruce Leff, MD Associate Professor Johns Hopkins University Schools of Medicine and Public HealthLet’s Think About…• Principles of ethical decision making• Cases• Advance directives• Ethics at the end-of-life• Research ethics• RationingBasic Principles of Ethical Decision Making• Autonomy• Beneficence• Justice• NonmaleficenceAutonomy• Personal rule of the self that is free from controlling influences of others (liberty) and from personal limitations that prevent meaningful choice, such as inadequate understanding (agency).Autonomy• The model of medical decision making over last 30 years• Implications-– Informed consent– Providing information - disclosure of diagnoses – 1960 v 2007– Involvement of patients in EOL decisions– Advance directivesOther Principles• Beneficence – acting for the benefit of others (patient )• Justice (distributive) – fair, equitable, and appropriate distribution in society (NH)• Nonmaleficence – do no harm – primum no nocereRealize…• Ethical• Legal• PracticalCase• 88 yo woman• Lives alone, no family• Owns home• Mildly demented• House is a mess• You make a housecall• Worry about her safety• “I don’t want to go anywhere”What ethical principles are in play?How should you approach a decision?What would you do?Case• 64 yo m – NH res• Alcoholism• B AKAs• L hemiplegia• No family / visitors• Dependent ADLs• Never liked NH – cigs in bed, refused care, sex advances with staff• Purchased motorized WC• Off campus, got drunk, behavior worsened, disrupted unit• Staff asks you to take away his wheelchair• Fell out WC, accident, rib fx• What ethical principles are in play?• How should you approach a decision?Advance Directives• Assessing patient wishes when can’t speak for self – Cruzan 1990 – constitutional basis for competent patients to direct their future medical treatment through the execution of an advance directive• Advance directives– Living wills– Durable power of attorney for health care– Verbal statements to primary care physician or family members• PSDA 1990 - Federal law requiring states to education patients entering institutions regarding advance directivesProblems with Advance Directives• Vague language – “heroic,” “extraordinary”• Difficult to anticipate future medical scenarios• Change mind• PortabilityProblems with Advance Directives• Is this the right thing to require from an ethical perspective?– Cultural influences – asian, navajo• Are ADs used? Do they improve care? Do they save money?– SUPPORT study – large RCT of nurse intervention to enhance use of AD and enhance EOL care for pts hosp with 50% 6 mo survivalSUPPORT Study• Intervention - No improvement in:– MD-pt communication re discuss CPR preferences– Incidence or timing of written DNR orders– MD knowledge of pts preferences for DNR– # days in ICU, receiving mechanical ventilation, comatose b/f death– Pain level– Use of hospital resourcesEthics at the End of Life• What conceptually is the difference between killing and letting die?• Is foregoing life-sustaining treatment sometimes a form of killing, and is so, is it sometimes suicide and sometimes homicide?• Under what conditions, if any, is it permissible for patients, health professionals, or surrogates to forgo treatment so that the patient dies, to arrange for assisted suicide, or to arrange for some other cause of death?Ethical Issues at EOL - Euthanasia• Active – lethal intervention. Netherlands.• Passive: withdrawal of care, e.g artificial nutrition and hydration. Ethically no different from withholding care• Assisted: by physician (supplies means)– Quill’s letter to NEJM in 1991 signaled public discussion– Supreme court – 1997 – washington v glucksberg, vacco v quill – no constitutional right to secure assistance of physician to actively hasten their own deaths, and states may continue to make a physician’s assistance in such cases criminal offense. Court left open possibility that states could decriminalize PAS if they choose to do so. Oregon has done so.Research Ethics• Informed consent for care– Competence to give informed consent– Competent patients have right to refuse treatment– Ethical dilemma of caring for incompetent, dying patient• Making treatment / consent decisions for incapacitated older adults without advanced directivesHealth Care Rationing• Callahan, Setting Limits, – Rationing happens as it is: – Don’t allow expensive medical technology after about age 80• Daniels– Proposes a prospective national policy/ consensus• Veatch– Persons would receive “priority claims” in inverse proportion to chronological