LEGAL AND ETHICAL ISSUES IN GERIATRICS

Geriatric medicine & nursing is ethically complex.

Ethics combines the discipline of philosophy, behavioral science, law and medicine to
resolve the moral issues and conflicts.
Common legal and ethical issues are decision making, competence etc.

Need of legal and ethical security in geriatrics

Due to automatic and unthoughtful process of health care system .
Costly, risky treatment and outcome are uncertain.
Impair communication and cognition for decision making.

Ethical Principles
Principle of beneficence : what is the best for the patient. Technical expertise &
compassionate care.
Respect for persons : Basic respect for self-determination & autonomy.
Example- right to refuse.
Principle of fidelity: Relationship with patient, trust & confidentiality.
Principle of justice : Equitable treatment & distribution of resources.

Types of legal and ethical issues

1. Capacity
A clinical determination of patient’s ability to make decisions about treatment interventions
or other health related matters.
 Decisional capacity
 Partial capacity(short term memory loss)
 Incapacity (scare, confusion, intimidate)
2. Competence
A legal designation that recognizes that persons beyond a certain age generally have the
cognitive ability to negotiate certain legal tasks, such as entering contract or making a will.
3. Informed consent
A decisionally capable patient’s legally reached binding treatment decision reached
voluntarily based on information about risks, benefits and alternative treatments gained from
discussion with health care practitioner.
Informed Consent
 Voluntary choice of a competent patient.
 It is part of the concept patients’ right to self- determination.
 Informed consent gave patients the right to choose how they would be treated.
Informed consent is the process by which the patient determines whether to accept or
refuse the treatment offered by a physician or another clinician.
 The main determination for informed consent is decisional capacity
Informed Consent -Elements to include in discussion:

• The specific condition requiring treatment

• The purpose and distinct nature of the procedure or treatment
• Potential complications or risks associated with the procedure or treatment
• Reasonable alternatives with a discussion of their relative risks and benefits
• Discussion of the option of taking no action
• The probability of success of the recommended treatment or procedure
4. Confidentiality and disclosure
Ethical oaths and specific statutes protect the confidentiality of physician patient
communication, ethical and legal bedrock of the therapeutic relationship.
Protection of patient’s secretes private thoughts and feelings required by decency.
5. Advance care planning
 Patients with decisional capacity have the right to make decisions that their medical
teams and families don’t agree with.
 Elderly patients often have chronic and ultimately fatal illnesses.
 The patients are often unable to make decisions. One strategy to make these difficult
decisions is to make them in advance when the patient is competent.
 Advance care planning describes competent patients discussing and may documenting
their preferences for future medical care.
Living will: A document describing a patient’s preferences for the initiation, continuation, or
discontinuation of particular forms of treatment.
Durable power of attorney (DPA)/ health care proxy: A document that designates a
surrogate (also called an “agent,” “proxy,” or “attorney-in-fact”) to make medical decisions
on a person’s behalf should that person become unable to make a decision.
Oral statements: that arise in conversations with family, friends, and physicians are
recognized ethically, and in some states legally, as advance directives, if properly charted in
medical records.
Surrogate decision making: A surrogate is a statutorily designated health care decider or an
informally identified person ,such as a close family member or friend. If the patient is
incapacitated and no advance directive exists some other or persons must provide the
direction (either a loved one or medical or nursing staff).
6. Do-Not-Resuscitate Orders:
A statement in the medical record that cardiopulmonary resuscitation will not be performed.
DNR does not mean do not treat.

7. Withholding of Food and Fluid

The artificial administration of food and fluid is a medical treatment subject to the same
strictures that guide other medical decisions.
8. Euthanasia, Assisted suicide, and Palliation:
Euthanasia, It is an action taken by a health care practitioner intended to results in
patient’s death.
Assisted suicide, an action taken by a patient intended to cause his own death with drug
supplied a physician, is illegal.
Palliation, or pain relief, is extricable form that of assisted suicide.
9. Discharge and Placement:
 Medical and nursing practitioners and family members routinely make decisions
about discharge and placement without adequately consulting the patient and often
over the patient’s objections.
 But capacitated patients have the rights to choose their living agreements and
outpatient care.
10. Long-Term care
Long term care facilities are now being challenged about policies that automatically
hospitalize residents at the end of life or that impose life-sustaining treatment with no
provision for evaluating, preventing, or terminating such treatment.
Goals of care of elderly
1. Cure
2. Life prolongation
3. Participation in a future event
 4. Remain independent
5. Maintain clear thinking
6. Maximize comfort
The special settings for Ethical Dilemmas
The Hospital settings –
Decision making and consent capacity
The Nursing home settings-
Surrogate Decision making
The Home settings-
Surrogate decision making and capacity
The Out-patient or Clinic settings -decision making, capacity

Ethics in Practice
 Nurses must prepare for such dilemmas by considering the influence of their own
personal values, attitudes, and expectations about aging on the care of older adults and
their families. Without such reflections, the patient may lose autonomy, the right to
self-determination, and justice.
 Nurses must learn how to assess competency as related to specific features of care in
the geriatric population. Developing skills in probing the expressed wishes of patients
and advocating for those wishes to be followed facilitates respect and the honoring of
self-determination.
 Nurses also need to recognize that clarity of thought is fluid and lucid moments can
return or appear. These moments should be recognized and viewed as opportunities
for discussion.
 Nurses, as patient advocates, also bear responsibility for effective communication of a
patient’s preferences through documentation and reporting processes. They are also
responsible for creatively thinking about and problem-solving situations that limit
functional status and safety to support quality of life and independent living.
 Nurses caring for children and younger adults bear a responsibility to facilitate
healthy life choices to minimize future health complications, including being good
role models of healthy behaviors themselves.
 Mistakes
Mistakes happen, and happened more often than the public was aware of prior to the 2000
report by the Institute of Medicine that stated such errors are common and often life
threatening (Kohn, Corrigan, & Donaldson, 2001).
Since that time, considerable effort has been put into reducing mistakes and improving
patient safety. However, even the most conscientious nurse will make a mistake or two.
Responding to mistakes is intimidating, embarrassing, and risky for most.
Ethical responses to mistakes include:
• Honestly admitting the error occurred in a neutral and objective manner
• Taking proper steps to correct the situation
• Apologizing for the mistake
• Making amends as possible
• Evaluating how to prevent such mistakes in the future
Disclosure of mistakes in an honest and willing manner reduces the threat of the situation and
also reduces the threat of liability

Conflict of Interest
Conflict of interest situations arise from competing loyalties and opportunities. This may
include conflicts of values between the nurse’s value system and choices made by the
patients, their families, other health care team members, the organization, or the insurance
company. This is particularly evident in discussions related to resource allocation and end-of-
life care. Other conflicts occur when incentive systems or other financial gains create conflict
between professional integrity and self-interest. Nurses should facilitate resolution of
conflicts by disclosing potential or actual conflicts of interest or withdraw from participation
in care or processes that are causing the conflict (ANA, 2005a).

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