Textbook Ethical Considerations and Challenges in Geriatrics 1St Edition Angela Georgia Catic Eds Ebook All Chapter PDF

Ethical Considerations and Challenges
in Geriatrics 1st Edition Angela Georgia

Catic (Eds.)
Visit to download the full and correct content document:
https://textbookfull.com/product/ethical-considerations-and-challenges-in-geriatrics-1s
t-edition-angela-georgia-catic-eds/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...
Research in Deaf Education: Contexts, Challenges, and

Considerations 1st Edition Stephanie Cawthon
https://textbookfull.com/product/research-in-deaf-education-
contexts-challenges-and-considerations-1st-edition-stephanie-
cawthon/
Emiratization in the UAE Labor Market Opportunities and

Challenges 1st Edition Georgia Daleure (Auth.)
https://textbookfull.com/product/emiratization-in-the-uae-labor-
market-opportunities-and-challenges-1st-edition-georgia-daleure-
auth/
Functional Variations in English Theoretical

Considerations and Practical Challenges Ram Ashish Giri
https://textbookfull.com/product/functional-variations-in-
english-theoretical-considerations-and-practical-challenges-ram-
ashish-giri/
Compelling Ethical Challenges in Critical Care and

Emergency Medicine Andrej Michalsen
https://textbookfull.com/product/compelling-ethical-challenges-
in-critical-care-and-emergency-medicine-andrej-michalsen/
Development of Antibody Based Therapeutics
Translational Considerations Challenges Mohammad A.
Tabrizi
https://textbookfull.com/product/development-of-antibody-based-
therapeutics-translational-considerations-challenges-mohammad-a-
tabrizi/
Geriatrics for Specialists 1st Edition John R. Burton
https://textbookfull.com/product/geriatrics-for-specialists-1st-
edition-john-r-burton/
Algorithmic Governance And Governance Of Algorithms:

Legal And Ethical Challenges Martin Ebers
https://textbookfull.com/product/algorithmic-governance-and-
governance-of-algorithms-legal-and-ethical-challenges-martin-
ebers/
Long Term Forensic Psychiatric Care Clinical Ethical

and Legal Challenges Birgit Völlm
https://textbookfull.com/product/long-term-forensic-psychiatric-
care-clinical-ethical-and-legal-challenges-birgit-vollm/
Surgical Decision Making in Geriatrics A Comprehensive

Multidisciplinary Approach Rifat Latifi
https://textbookfull.com/product/surgical-decision-making-in-
geriatrics-a-comprehensive-multidisciplinary-approach-rifat-
latifi/
Ethical
Considerations
and Challenges
in Geriatrics
Angela Georgia Catic

Editor
123
Ethical Considerations and Challenges
in Geriatrics
Editor
Ethical Considerations and

Challenges in Geriatrics
Editor
Department of Internal Medicine
Section of Geriatrics
Baylor College of Medicine and Michael E. DeBakey VA Medical Center
Houston TX
USA
ISBN 978-3-319-44083-5 ISBN 978-3-319-44084-2 (eBook)

DOI 10.1007/978-3-319-44084-2
Library of Congress Control Number: 2017930971
© Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.
Printed on acid-free paper
This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
1 Geriatric Epidemiology �� 1

Angela G. Catic
2 Evaluating Capacity for Safe and Independent Living Among
Vulnerable Older Adults�� 9
Aanand D. Naik
3 Surrogate Decision-Making and Advance Care Planning�� 23
Ursula K. Braun
4 End-of-Life Care of Older Adults�� 35
Lara M. Skarf and Andrea Wershof Schwartz
5 Special Considerations in Older Surgical Patients �� 51
Lauren J. Gleason and Angela G. Catic
6 Ethical Issues of Renal Replacement Therapy in the Elderly�� 63
Austin Hu and Medha Airy
7 Ethical Considerations for the Driver with Dementia�� 75
Geri Adler and Susan J. Rottunda
8 Medical Futility�� 87
Gregory A. Holton and Angela G. Catic
9 Feeding Issues in Advanced Dementia �� 101
Nicolin Neal and Angela G. Catic
10 Intimacy in the Long-Term Care Setting�� 111
John W. Culberson, Totini Chatterjee, and Fiona Prabhu
11 Elder Abuse and Neglect�� 123
John M. Halphen and Carmel B. Dyer
12 Hospital and Physician Rating Websites: Ethical Challenges
Without Context�� 137
George E. Taffet
v
vi Contents
13 Considerations and Challenges in Information and

Communication Technology�� 147
Bradley H. Crotty
14 Ethical Issues in Geriatric Research�� 157
Lisa Boss, Sandy Branson, and Sabrina Pickens
Index�� 169
Contributors
Geri Adler, PhD, MSW South Central Mental Illness Research, Education &
Clinical Center, Houston VA Health Services Research & Development Center for
Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine,
Houston, TX, USA
Medha Airy, MD Internal Medicine, Nephrology Section, Baylor College of
Medicine, Houston, TX, USA
Lisa Boss, PhD, RN, ACNS, CEN School of Nursing, The University of Texas
Health Science Center at Houston, Houston, TX, USA
Sandy Branson, PhD, MSN, RN School of Nursing, The University of Texas
Ursula K. Braun, MD, MPH Baylor College of Medicine, Department of
Medicine, Division of Geriatrics, Michael E. DeBakey VA Medical Center, Houston,
TX, USA
Angela G. Catic, MD Department of Internal Medicine, Section of Geriatrics,
Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston,
TX, USA
Totini Chatterjee, BS Internal Medicine, Texas Tech University Health Sciences
Center, Amarillo, TX, USA
Family and Community Medicine, Texas Tech University Health Sciences Center,
Lubbock, TX, USA
Bradley H. Crotty, MD, MPH Department of Medicine, Medical College of
Wisconsin and Froedtert Hospital, Milwaukee, WI, USA
John W. Culberson, MD Family and Community Medicine, Texas Tech Health
Sciences Center Lubbock, Lubbock, TX, USA
Carmel B. Dyer, MD, FACP, AGSF Department of Internal Medicine, Division of
Geriatric and Palliative Medicine, University of Texas Health Science Center at
Houston, Houston, TX, USA
vii
viii Contributors
Lauren J. Gleason, MD, MPH Department of Medicine, Section of Geriatrics

and Palliative Medicine, The University of Chicago Medicine, Chicago, IL, USA
John M. Halphen, JD, MD Department of Internal Medicine, Division of
Geriatrics and Palliative Medicine, McGovern Medical School, University of Texas
Gregory Holton, MD Internal Medicine, Baylor College of Medicine, Houston,
TX, USA
Austin Hu, MD Internal Medicine, Baylor College of Medicine, Houston, TX,
USA
Aanand D. Naik, MD Houston Center for Innovations in Quality, Effectiveness
and Safety (IQuESt), Baylor College of Medicine and Michael E. Debakey VA
Medical Center, Houston, TX, USA
Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
Nicolin Neal, MD Post Acute Care, IPC Healthcare, Houston, TX, USA
Sabrina Pickens, PhD, MSN, GNP-BC, ANP-BC School of Nursing, The
University of Texas Health Science Center at Houston, Houston, TX, USA
Fiona R. Prabhu, MD Department of Family and Community Medicine, TTUHSC
School of Medicine, Lubbock, TX, USA
Susan J. Rottunda, BS Minneapolis VA Health Care System, Geriatric Research,
Education and Clinical Center (GRECC), Minneapolis, MN, USA
Andrea Wershof Schwartz, MD, MPH Harvard Medical School, Geriatrics and
Palliative Care, GRECC, VA Boston Health Care System, Boston, MA, USA
Lara M. Skarf, MD Section of Geriatrics and Palliative Care, Medical Service,
VA Boston Healthcare System, West Roxbury, MA, USA
George E. Taffet, MD, FACP Chief Geriatrics, Geriatrics and Cardiovascular
Sciences, Robert J. Luchi, M.D. Chair in Geriatric Medicine, Head of the Division
of Geriatrics, Methodist Hospital, Baylor College of Medicine, Houston, TX, USA
Geriatric Epidemiology
1
Angela G. Catic
Introduction
Secondary to declining fertility and increasing life expectancy, the median age of
the world’s population is increasing leading to significant epidemiological changes
including challenges within healthcare and social services. Throughout the twenti-
eth century, fertility rates have declined in developed countries, and this decline has
spread to developing countries over the last 30 years [1]. Increasing life expectancy
has also contributed significantly to the aging of the population. During the twenti-
eth century, life expectancy in developed countries increased by 71 % for females
and 66 % for males. This was initially due to decreased childhood mortality, but,
over the last several decades, gains are due to individuals living into advanced old
age (>85 years).
Due to declining fertility rates and increased longevity, the geriatric population
will increase significantly over the next several decades. While only 4 % of the US
population was 65 years or older in 1900, the percentage of the population com-
prised of elders has increased significantly over the last century and is expected to
continue to increase: 9.8 % in 1970, 13 % in 2010, and 20 % by 2050 [2]. In terms
of actual numbers, the number of individuals age 65 years and older in the USA is
anticipated to increase from 43.1 million in 2012 to 83.7 million by 2050 [2]. The
aging of the population is not only occurring in the USA but throughout the world.
There were 901 million individuals age 60 years or older worldwide in 2015 and
this is projected to increase to 1.4 billion by 2030 and 2.1 billion by 2050 [3]. The
aging trend is anticipated to be especially significant in lesser developed, generally
younger countries such as Latin America and the Caribbean where there will be a
70 % increase in the number of elders over the next 15 years. During this same time
A.G. Catic, MD
Department of Internal Medicine, Section of Geriatrics, Baylor College of Medicine and
Michael E. DeBakey VA Medical Center, Houston, TX, USA
e-mail: angela.catic@va.gov
© Springer International Publishing Switzerland 2017 1

A.G. Catic (ed.), Ethical Considerations and Challenges in Geriatrics,
DOI 10.1007/978-3-319-44084-2_1
2 A.G. Catic
period, it is projected that the geriatric population of Africa and Asia will increase
>60 %. In contrast, the population in Europe is already much older, so the elderly
population is anticipated to increase by 23 % over the next 15 years [3].
Within the generalized aging trend, there continue to be disparities in longevity
between men and women. Throughout the world, older women have a longer life expec-
tancy than men and therefore comprise a larger percentage of the population. Between
2000 and 2030, women will account for 56–59 % of the elderly US population [4]. This
gender gap is even more significant among the oldest-old (>85 years of age) where there
are two to five times as many elderly women as men. This trend is expected to continue
with females born in 2012 living 5 years longer than their male contemporaries [5].
The US geriatric population will become increasingly racially and ethnically
diverse over the next several decades. This is secondary to the aging of individuals
who immigrated to the country when they were younger as well as immigration
among elderly individuals, especially from Latin America, Asia, and Africa. In
2013, 21.2 % of elderly Americans were members of racial or ethnic minorities and
this is expected to increase to 28.5 % by 2030 [6].
Lesbian, gay, bisexual, and transgender (LGBT) individuals also represent a
growing demographic within the elderly population. It is estimated that there are
between 1.75 and 4 million LGBT elders ≥60 years of age and this is expected to
double by 2030 [7, 8]. Elders who are LGBT have significant physical and mental
health disparities compared to their heterosexual contemporaries including higher
rates of feeling isolated and contemplating suicide. Unfortunately, many providers
lack knowledge regarding the special health issues of this population.
The changing demographics of the geriatric populations have important medical,
social, and ethical implications which will continue to develop over the next several
decades. As the US government, medical systems, communities, and families adapt to the
challenges of an aged population, an understanding of the unique medical and social needs
of the geriatric population will help to ensure they receive ethical, individualized care.
Medical Implications of the Aging Population
Acute Versus Chronic Illness
In juxtaposition to past experience, there has been a shift in the leading causes of
death from acute illness to chronic disease. Chronic conditions are defined as condi-
tions lasting ≥1 year which require either ongoing medical attention or that limit
activities of daily living [9]. In 2012, chronic diseases accounted for 68 % of all
deaths with cardiovascular disease, cancer, chronic lung disease, and diabetes being
most prevalent [10]. In the USA, the top ten causes of death among people aged 65
years and older are heart disease, malignancy, chronic respiratory disease, cerebro-
vascular disease, Alzheimer disease, diabetes, influenza and pneumonia, nephritis,
unintentional injury, and septicemia [11].
The transition from acute to chronic illness as the leading cause of mortality
represents a significant challenge for the healthcare system. Among individuals in
1 Geriatric Epidemiology 3
the geriatric age group, chronic conditions are common, costly, and morbid. Three
in four Americans age 65 years or older suffer from multiple chronic conditions
[12]. Care for individuals with multiple chronic conditions accounts for 71 % of
total healthcare spending in the USA, and, among elderly Medicare beneficiaries,
this increases to 93 % of Medicare spending [13, 14]. With each chronic condition
developed, the risk of impaired daily function, hospitalization, and premature death
increases [12]. Over the next several decades, as continued growth in the number of
elders with one or more chronic illnesses results in increasing strain on the health-
care system, providing high-quality, evidenced-based care will be critical to improv-
ing patient outcomes and minimizing financial burden.
Polypharmacy
As individuals are living longer and suffering from multiple chronic illnesses, many are
taking numerous medications. This is reflected by the fact that elders comprise slightly
more than 13 % of the population but consume 40 % of prescription medications and
35 % of over-the-counter drugs [15]. On average, individuals between 65 and 69 years
of age take 14 prescriptions per year, and this increases to 18 per year among elders
80–84 years of age [15]. Unfortunately, increasing numbers of medications are associ-
ated with greater risk of adverse drug reactions and side effects. Among community
dwelling elders, one in three taking ≥5 medications will have an adverse drug reaction
within 1 year [16]. It is estimated that at least 350,000 adverse drug events occur annu-
ally in long-term care residents and more than half of these are preventable [17]. In
addition, despite the implementation of Medicare Part D prescription drug benefits in
2006, drug costs continue to be a significant financial strain for many elders. This often
leads to difficult decisions about how financial resources will be spent (i.e., food and
rent versus medications) and medication noncompliance. When making medication
decisions in the elderly, clinicians should incorporate the ethical principles of non-
maleficence (not inflicting intentional harm) and beneficence (having the best interest
of the patient at heart). Careful consideration should be given to the patient’s goals of
medical care when considering the addition or discontinuation of any medication. In
addition, the possible risks and benefits of all medications should be carefully reviewed
so that patients can make an informed decision prior to starting any new therapy.
Clinicians should have frank discussions with patients regarding the financial implica-
tions of their medication regimens and be open to considering lower-cost, alternative
therapies or assisting patients in pursuing sources of reduced cost pharmaceuticals.
Dementia
Dementia, or major neurocognitive disorder, typically occurs in individuals over

age 65 years and will have a significant impact on healthcare of the elderly over the
next several decades. Dementia is a general umbrella term used to refer to disorders
that cause significant decline in one or more areas of cognitive functioning (learning
4 A.G. Catic
and memory, complex attention, executive function, language, perceptual-motor,

and social cognition) and are severe enough to impact daily function. Worldwide,
nearly 44 million individuals suffer from dementia. Alzheimer disease, the most
common type of dementia, impacts 5.3 million Americans and this is projected to
skyrocket to 16 million by 2050. The prevalence of Alzheimer disease doubles
every 5 years after age 60 affecting 6–8 % of patients ≥65 years and 45 % or more
of those ≥85 years. Vascular dementia is estimated to cause 15–20 % of cases of
dementia. Other common etiologies of dementia include mixed dementia (Alzheimer
and vascular), Lewy body dementia, and frontotemporal dementia.
Providing care for the large number of elders who have, and will develop, dementia
in the near future presents significant financial and caregiving challenges. In 2010, the
total estimated worldwide costs for dementia were $604 billion annually [18]. These
costs included the direct costs of medical and social care; insurances including Medicare,
Medicaid, and private insurance; and informal care costs which fall primarily on the
families of individuals with dementia. In 2015, unpaid caregivers provided 18.1 billion
hours of unpaid care to loved ones with dementia with an estimated value of $221.3 bil-
lion [19]. On average, family caregivers lose over $15,000 in annual income and spend
> $5,000 for each elder with dementia [19]. Caregiving is not only associated with high
financial costs but increased stress and medical issues. Among dementia caregivers, 60
% rate their stress as high or very high, 40 % suffer from depression, and 74 % are con-
cerned about their own health in light of their role as a caregiver [19].
Surrogate Decision-Maker
Surrogate decision-makers, also referred to as a healthcare proxy or a durable power

of attorney for healthcare, make medical decisions on behalf of an individual who
has lost decision-making capacity. In a review of 3746 subjects 60 years of age and
older at the end of their life, 42.5 % required decision-making regarding medical
care during this time period [20]. Of these individuals, 70.3 % lacked decision-
making capacity and 67.6 % had previously completed advance directive docu-
ments. Subjects who had appointed a surrogate decision-maker were less likely to
die in the hospital or to receive all care possible (i.e., aggressive care) compared to
those subjects who did not have a designated decision-maker. This study highlights
the importance of encouraging patients to select a surrogate decision-maker as the
loss of capacity is a frequent occurrence and having an appointed decision-maker
can help to encourage patient autonomy.
Social Implications of the Aging Population
Health Literacy
Health literacy, which involves the ability to understand and use health information, is
critical to optimally managing health issues. Defined as “the degree to which
individuals have the capacity to obtain, process, and understand basic health informa-
tion and services needed to make appropriate health decisions,” it includes the ability
to follow directors, do basic math calculations, complete forms, and interact with the
healthcare system [21]. Health literacy can be influenced by basic literacy skills, edu-
cational level, socioeconomic status, ethnicity, communication skills of care provid-
ers, and specific health situations encountered. In the USA, >77 million adults have
basic or below basic health literacy skills. A significant percentage of older adults
have difficulty using printed health materials (71 %),forms or charts (80 %),and inter-
preting numbers and doing calculations (68 %) [22]. These challenges are particularly
concerning for elders, who often suffer from multiple chronic conditions and are high
uses of the healthcare system, as low health literacy has been associated with increased
morbidity, mortality, and healthcare costs. Using a tool to assess health literacy can
help providers to gauge potential challenges patients may face in navigating their
health and to modify the plan of care accordingly. Developed in 2005, the Newest
Vital Sign (NVS) is one available health literacy tool [23]. It is a quick, easy-to-use
screen which assesses math, reading, comprehension skills, and abstract reasoning.
Living Arrangements
Elders in the USA have diverse living arrangements which can have important
health implications. In 2015, 56 % of elderly noninstitutionalized individuals lived
with their spouse (70 % of older men and 45 % of older women) [24]. The propor-
tion of elders residing with their spouse decreased with advancing age. In contrast,
29 % of noninstitutionalized elders live alone and this proportion increases with
aging [24]. While a relatively small number (1.5 million or 3.2 %) of individuals 65
years of age or older live in institutional settings, this increases with advancing age:
1 % in individuals 65–74 years, 3 % in those 75–84 years, and 10 % in those >85
years [24]. Providers should discuss living arrangements with their elderly patients
to ensure that they are acceptable, safe, and provide the needed level of support
based on their healthcare needs.
Finances
The financial situation of many elders has important implications for their health
and social situation. In 2014, the median income of elders was $31,169 for males
and $17,375 for females [24]. Ten percent were below the poverty level and another
5.3 % were “near poor,” defined as income between the poverty level and 125 % of
the poverty level [24]. Elderly African-Americans and Hispanics were more likely
to meet criteria for poverty compared to Caucasians and Asians. In addition, the
following were associated with higher levels of poverty: female gender, living alone
as opposed to residing with family, and residing inside principal cities and/or in the
South. Elderly individuals reported the following sources of income: Social Security
(84 %), income from assets (51 %), earnings (28 %), private pensions (27 %), and
6 A.G. Catic
government employee pensions (14 %) [24]. Of note, Social Security comprised

≥90 % of income for 35 % of beneficiaries.
Conclusion
Within the USA, the population of individuals ≥65 years of age is rapidly
increasing in number and diversity with this trend expected to continue into the
foreseeable future. This demographic shift will require the healthcare system to
adapt in order to meet the medical, social, and ethical challenges of caring for
this population. From caring for large numbers of elders with chronic conditions
and dementia to relying more heavily on surrogate decision-makers to facing
challenges of low health literacy and poverty, clinicians will need to develop and
carry out individualized care plans to ensure the best possible health of each
patient.
References
1. Kinsella KV. An aging world. In: Bureau USC, editor. US Census Bureau. Washington, DC:
U.S. Government Printing Office; 2001; series P95/01-1;2001.
2. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States
population estimates and projections. Current Population Reports. May 2014. http://www.cen-
sus.gov/prod/2014pubs/p25-1140.pdf. Accessed 15 June 2016.
3. United Nations. World population ageing. 2015. http://www.un.org/en/development/desa/
population/publications/pdf/ageing/WPA2015_Highlights.pdf. Accessed 16 June 2016.
4. United Nations. Population Division. World population ageing 1950–2050. http://www.un.org/
esa/population/publications/worldageing19502050/pdf/62executivesummary_english.pdf.
Accessed 16 June 2016.
5. World Health Organization. World health statistics 2014. http://www.who.int/mediacentre/
news/releases/2014/world-health-statistics-2014/en/. Accessed 16 June 2016.
6. U.S. Department of Health and Human Services Administration for Community Living.
Administration on Aging. Minority aging. 2014. http://www.aoa.acl.gov/Aging_Statistics/
Minority_Aging/index.aspx. Accessed 16 June 2016.
7. Discrimination. Services and advocacy for gal, lesbian, bisexual, and transgender elders. 2016.
https://www.sageusa.org/issues/general.cfm. Accessed 3 July 2016.
8. Administration on Aging (AoA) Diversity. U.S. Department of Health and Human Services
Administration for Community Living. 12/31/1600. http://www.aoa.gov/AoA_programs/
Tools_Resources/diversity.aspx#LGBT. Accessed 3 July 2016.
9. US Department of Health and Human Services. Multiple chronic conditions- a strategic frame-
work: optimum health and quality of life for individuals with multiple chronic conditions.
2010. http://www.hhs.gov/sites/default/files/ash/initiatives/mcc/mcc_framework.pdf.
10. World Health Organization. The top 10 causes of death.Fact sheet N°310. May 2014. http://
www.who.int/mediacentre/factsheets/fs310/en/index4.html. Accessed 16 June 2016.
11. Centers for Disease Control and Prevention. 10 leading causes of death by age group, United
States. 2010. http://www.cdc.gov/injury/wisqars/pdf/10LCID_All_Deaths_By_Age_
Group_2010-a.pdf. Accessed 16 June 2016.
12. Centers for Disease Control and Prevention. Chronic disease prevention and health promotion.
24 May 2016. http://www.cdc.gov/chronicdisease/index.htm. Accessed 19 June 2016.
13. Gerteis J, Izrael D, Deitz D, et al. Multiple chronic conditions chartbook. AHRQ Publications
No, Q14-0038. Rockville: Agency for Healthcare Research and Quality; 2014. http://www.
ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/
mccchartbook.pdf. Accessed 19 June 2016.
14. Centers for Medicare & Medicaid Services. Chronic conditions among Medicare beneficiaries,
chart book 2012. Baltimore. 2012. https://www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf.
15. ASCP Fact Sheet. American Society of Consultant Pharmacists. 2016. https://www.ascp.com/
articles/about-ascp/ascp-fact-sheet. Accessed 22 June 2016.
16. Hanlon JT, Schmader KE, Koronkowski MJ, et al. Adverse drug events in high risk older out-
patients. J Am Geriatr Soc. 1997;370:185–91.
17. Avorn J. GrantWatch: medication use and the elderly: current status and opportunities. Health
Aff. 1995;14:1276–86.
18. World Alzheimer Report 2010. Alzheimer’s Disease International. 2010. http://www.alz.org/
documents/national/world_alzheimer_report_2010.pdf. Accessed 3 July 2016.
19. 2016 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association. 2016. Accessed 3 July
2016.
20. Silveira MJ, Kim SYH, Langa KM. Advance directives and outcomes of surrogate decision
making before death. N Engl J Med. 2010;362(13):1211–8.
21. U.S. Department of Health and Human Services. Healthy people 2010. Washington, DC:
U.S. Government Printing Office; 2000. Originally developed for Ratzan SC, Parker
RM. Introduction. In: National library of medicine current bibliographies in medicine: health
literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, editors. NLM Pub. No. CBM 2000–1.
Bethesda: National Institutes of Health, U.S. Department of Health and Human Services;
2000.
22. Kutner M, Greenberg E, Jin Y, Paulsen C. The health literacy of America’s adults: Results
from the 2003 national assessment of adult literacy (NCES-483). U.S. Department of
Education. Washington, DC: National Center for Educational Statistics; 2006.
23. Weiss BD, Mays MZ, Marz W, et al. Quick assessment of literacy in primary care: the Newest
Vital Sign. Ann Fam Med. 2005;3:514–22.
24. A profile of older Americans: 2015. Administration on Aging, Administration for Community
Living, U.S. Department of Health and Human Services. 2015. http://www.aoa.acl.gov/
Aging_Statistics/Profile/2015/docs/2015-Profile.pdf. Accessed 7 July 2016.
Evaluating Capacity for Safe
and Independent Living Among 2
Vulnerable Older Adults
Aanand D. Naik
Case Presentation
Mr. Davis is an 84-year-old widower who lives alone in an apartment having
retired from a long career as a corporate accountant. He ambulates with a roll-
ing walker but has some difficulty rising from a chair and gets short of breath
when walking across his home. He needs assistance with most instrumental
activities of daily living, which he receives from his daughter and son-in-law
who live 20 miles away. They help with driving but he remains insistent on
managing his own medications and basic finances. He is independent in most
basic activities of daily living but has some difficulty with bathing due to
osteoarthritis of both shoulders. His past medical history is remarkable for
ischemic cardiomyopathy with an ejection fraction of 30 %, atrial fibrillation,
diabetes mellitus, chronic renal insufficiency, lower urinary tract symptoms
with enlarged prostate, osteoarthritis of shoulders and knees, and gastro-
esophageal reflux disease. He takes more than a dozen medications (aspirin,
metoprolol, carvedilol, atorvastatin, dabigatran, metformin, sitagliptin, furo-
semide, finestride, tamsulosin, acetaminophen, vitamin B12, and esomepra-
zole) and has four regular physicians. Four months ago he was admitted to the
hospital due to heart failure exacerbation. At hospital discharge, he transi-
tioned to a skilled nursing facility for 3 weeks due to functional impairment
and multiple changes to his medications. After returning home, Mr. Davis’
daughter suggested helping him prepare his medications using a pill tray, but
he got angry and insisted that his memory was “just fine” and he would “man-
age his own damn pills.” About that time, she also noted some late utility bills
and his water was turned off for several days, which Mr. Davis blamed on the
mail service not delivering his payment on time.
A.D. Naik, MD
Houston Center for Innovations in Quality, Effectiveness and Safety (IQuESt),
Michael E. Debakey VA Medical Center, Houston, TX, USA
Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
e-mail: aanand.naik@va.gov; anaik@bcm.edu

DOI 10.1007/978-3-319-44084-2_2
10 A.D. Naik
Despite getting his water service turned back on without his family’s involve-
ment, Mr. Davis’ daughter had her father see a neurologist as she was worried
that he was developing Alzheimer’s dementia. The neurologist conducted a
series of tests and noted that Mr. Davis has minimal changes on an MRI con-
sistent with his vascular disease and a score in the normal range on a dementia
screening test. His memory was appropriate for his age and education. On
examination, he was pleasant with refined social graces and was able to express
clear preferences. He reports feeling fine and states that he came to the neu-
rologist only at his daughter’s insistence. His neurological examination was
otherwise unremarkable. The neurologist didn’t find compelling evidence for
Alzheimer’s and recommends increasing his blood pressure medication to
reduce his cardiovascular risk factors. Mr. Davis was doing well for the next
month but then became acutely short of breath requiring another hospital
admission for heart failure exacerbation. The admitting physician noted that
Mr. Davis had gained 10–15 pounds since he was discharged from the hospital
previously and his lungs had evidence of extravascular overload. Mr. Davis
was able to describe his medications but also admitted he occasionally skips
his furosemide dose because he gets frustrated with having to go to the toilet
too frequently, especially at night. He was discharged home with skilled nurs-
ing care to help with medications and teaching for several weeks. His shortness
of breath improved, but he complains that some days he feels lightheaded and
he does seem to have more difficulty with getting dressed and bathing.
Mr. Davis has always been an independent person since he was 15 years old and
took pride in being the one others turned to for help. He isn’t worried about
death but insists that his only wish is to live in his home until he dies. He is will-
ing to accept some help from his daughter and son-in-law but doesn’t want any
strangers in his home. His daughter has become frustrated and tired as she now
spends many more hours each week helping Mr. Davis with his activities of
daily living and, when her father allows, supervising his medications and bills.
She also worries about his safety when she is not at his home. At her wit’s end,
she comes to a local geriatric medicine clinic asking for guidance about how to
manage her father, his safety, and if there are issues related to his competence.
Capacity for Safe and Independent Living
Mr. Davis has many of the characteristics of vulnerability [1]. Vulnerable older adults
often present with recurrent morbidity (frequent readmissions and emergency depart-
ment visits, adverse events related to medications, accidents and falls, etc.), despite
availability and access to preventive therapies. They are also at high risk for harm
including physical abuse, caregiver neglect, and financial exploitation. While cogni-
tive impairment and depression are often associated with vulnerability and self-
neglecting behaviors, this vulnerability does not typically result in complete
incapacity to make decisions. Mr. Davis’ neurological evaluation is consistent with
2 Evaluating Capacity for Safe and Independent Living Among Vulnerable Older 11
this observation as his cognitive impairments were minimal and decision-making

capacity remains mostly intact. However, as evidenced by the details of Mr. Davis’
story, the capacity to identify, avoid, and remove oneself from harmful situations
may be diminished. The clinical ethics consideration in these situations of vulnera-
bility is determining whether or not a patient can both make and execute decisions
regarding personal needs, health, and safety. In other words, does the individual have
the capacity to make and execute decisions for safe and independent living? [2].
From a legal perspective, declarations of competence are often treated as a dichoto-
mous phenomenon. One has capacity until a threshold is reached and then compe-
tence is lost. In situations of complete incompetence, access to treatment and legal
rights can be taken away. Recent advances in the legal understanding of competence
now include allowances for partial competence in which most rights and abilities are
maintained except for narrow declarations of incompetence (e.g., medical decisions,
voting, managing finances). However, in these declarations, the determination of
competence is exclusively related to decision-making capacities [3]. In contrast, the
capacity for safe and independent living is based on a two-dimension model of auton-
omy: decision-making and executive autonomy. These two dimensions are better
characterized later in this chapter. Furthermore, the capacity for safe and independent
living is best understood as a gradient rather than as a threshold phenomenon. This
distinction is important to avoid unnecessary infringements of patients’ rights. As a
clinical phenomenon, the health-care team can identify a range of medical and psy-
chosocial interventions to address some of the impairments contributing to declines in
the capacity for safe and independent living. If the impairments are too severe, inter-
ventions fail to ameliorate them, or an older adult refuses to implement these interven-
tions, then legal steps may be considered to more fully redress persistent deficits in
capacity. With this approach, medical and social interventions are applied first and
foremost before burdening the legal and governmental support systems.
Educational Pearl #1
• Vulnerability among older adults is best understood as impairments in the
capacity to make and execute decisions regarding one’s health, safety, and
independence (this includes the abilities to recognize and to extricate one-
self from harmful situations).
• Problems arise because, legally, capacity is often viewed as an all-or-
nothing phenomenon.
–– Capacity should be viewed along a clinical gradient.
–– Treatments and interventions should focus on maintaining as much of
the older adult’s autonomy as possible without compromising health
and safety.
–– Legal intervention, in the form of guardianship, is a last resort.
• When older adults lack this capacity, they are susceptible to medical mor-
bidity and harms from self-neglect and elder mistreatment.
12 A.D. Naik
• In the USA, approximately 5 million older adults are exposed to these

harms annually, including:
–– Physical violence
–– Emotional or psychological abuse (i.e., infantilizing the older adult)
–– Financial exploitation (includes material exploitation)
–– Neglect (intentional and unintentional)
–– Self-neglect
Two-Dimension Model of Autonomy and Capacity
Our clinical model of capacity for safe and independent living is grounded in the
clinical ethics foundations of Faden and Beauchamp’s Theory of Autonomous
Action [4]. Their general theory of what makes action, not just decisions, autono-
mous was grounded on three principles: understanding, intentionality, and volun-
tariness. Understanding is defined by actions based on understanding of situation
and choices. Understanding exists when an individual has the ability to (a) com-
prehend the circumstances and facts of a situation, (b) appreciate the personal
consequences of each choice and/or action, and (c) demonstrate a rational process
for choosing one versus another option. Intentionality is the state where actions
are willed and performed according to one’s plan. For intentionality to exist, indi-
viduals must have the ability to make and express preferences and choose a single
option, develop strategies and tactics for executing a choice, and ensure the per-
formance of strategies and adaptations to changing circumstances. Voluntariness
is defined by an ability to act without controlling influences. This is manifested
when actions are free of external coercion or manipulation and not compelled or
inhibited by internal impairments. Adapting these three pillars of autonomous
action to clinical care, it becomes clear that ethical standards based only on a
capacity to make informed decisions is inadequate. Such standards do not con-
sider most of the intentionality principle and part of the voluntariness principle.
In response to this ethical gap and clinical need, we have previously proposed a
two-dimension model of capacity, especially as it relates to the capacity for safe
and independent living [5].
Our two-dimension model of capacity includes the dimensions of decision-
making capacity and executive capacity. In this model, decision-making capacity is
“the process of making decisions for oneself or extending that power to another
individual when it is impaired” and executive capacity is the “process of carrying
one’s decision into effect either alone or by delegating those responsibilities to
another individual.” When applying this model to clinical care, especially the capac-
ity for safe and independent living, both dimensions should be evaluated indepen-
dent of one another.
Decision-making capacity is a well-studied area with conceptual and empirical
foundations. Appelbaum and Grisso’s empirically grounded model of decision-making
capacity is defined by four criteria that parallel the Faden and Beauchamp’s under-
standing principle described above. Applying these criteria to vulnerable older adults,
an individual must understand the basic facts surrounding a decision; appreciate the
personal impact of the decision, including one’s capabilities and limitations; have a
reasoning process for comparing the options and predicting the consequences of alter-
native choices; and be able to make a choice [6]. These criteria are the basis for most
informed consent documents and similar legal declarations related to the capacity to
consent for treatment (medications, diagnostic tests, surgery, and other therapeutic or
diagnostic procedures).
In contrast to decision-making, executive capacity is the ability to execute one’s
decisions. Executive capacity is not the same construct as executional or perfor-
mance capacity. Individuals with physical disabilities may not be able to perform
their activities of daily living on their own. However, nearly all have the capacity to
ensure that these activities are done appropriately and on time by other caregivers.
In this sense, executive capacity is the ability to ensure that one’s decisions have a
predetermined plan, adapt that plan in response to changing or unexpected circum-
stances, and delegate these responsibilities to appropriate caregivers or surrogates
when necessary or appropriate.
The interaction of decision-making and executive capacity in the context of the
capacity for safe and independent living can be complex. Vulnerable older adults,
such as Mr. Davis, retain some or all of their ability to make decisions about being
admitted to the hospital or moving into long-term care but lack the ability to
safely and effectively manage their medications or pay bills on time. From a clini-
cal perspective, it may be difficult, and often impractical, to determine whether
impairments are purely executive in nature or a mix of impairments in decision-
making and executive capacity. A practical approach grounded in the functional
domains of the activities of daily living are needed to better clarify how impair-
ments in the capacity for safe and independent living impact health and safety in
daily life.
The capacity for safe and independent living is based on two distinct
dimensions:
Decision-making capacity—does the vulnerable older adult have the
capacity to make decisions regarding safe and independent living?
Evaluated using four criteria:
• Understanding the basic facts surrounding a decision

• Appreciating the personal impact of the decision
• Reasoning through the options by comparing them and predicting the con-
sequences of those options
• Choosing an option
14 A.D. Naik
Executive capacity—does the vulnerable older adult have the capacity to

implement decisions (by themselves or with the assistance of others) regard-
ing safe and independent living?
• Having a plan
• Adapting the plan when circumstances change
• Delegating responsibilities if one cannot physically enact the plan
The Functional Domains of Safe and Independent Living
For clinicians, it is important to move from theoretical concepts of capacity to practical

domains that aid clinical assessment and intervention planning. Clinicians are often
asked to assess vulnerable older adults, like Mr. Davis, who demonstrate declines in
self-care behavior, live in unsafe settings, or have frequent exacerbations of treatable
chronic conditions. The first step of this evaluation is to identify how impairments pres-
ent within the context of five broad functional domains for safe and independent living:
maintaining personal needs and hygiene, condition of the home environment, main-
taining activities for independent living, health-care self-management, and managing
financial affairs.
Personal needs and hygiene include the basic physiological needs for personal liv-
ing and safety, for example, activities of daily living (ADLs) such as bathing, dress-
ing, sleeping, toileting, and feeding. Transferring and ambulation within the home are
other aspects of personal needs and hygiene. The condition of one’s home environ-
ment includes routine maintenance, appropriate repairs, and the physical structure of
the living environment. Respect for differences in lifestyle choices and cultural stan-
dards must be honored and respected. However, living situations and environments
that threaten one’s basic health or safety are not ethical and warrant a clinical evalua-
tion. Dangerous environments include those with excessive exposure to toxins from
pet and animal waste, accidents related to fire and electrical hazards, extremes in
weather, and pathogens arising from garbage and sewage. Clinicians may examine
whether patients understand their personal and environmental needs and the health
and safety risks arising from the gap between their needs and current status. Patients
should be able to participate in making a plan to accomplish tasks that address these
gaps. Patients physically unable to perform the appropriate tasks may still retain
capacity by identifying appropriate social and caregiver supports to fulfill these needs.
The other three functional domains include many functions classically thought
of as instrumental activities of daily living (IADLs). Instrumental activities of inde-
pendent living include shopping and meal preparation, laundry and cleaning, using
the telephone, and transportation. Here again, executive capacity is a key consider-
ation. Most vulnerable adults have begun to experience physical impairments and
disabilities that limit the ability to personally perform these instrumental activities.
However, most still retain executive capacity to participate in planning and ensure
execution of these tasks by formal and informal caregivers. Management of health
care and financial affairs is differentiated from the other activities for independent
living because of their specific correlations to medical morbidity and elder mistreat-
ment that often present to health-care and social services professionals, respectively.
Health-care self-management includes all the routine activities associated with
managing a medication regimen, monitoring of blood pressure or glucose, wound
care, attending to medical appointments and tests, and communicating with profes-
sionals about changes in health status. For example, assessment of this domain
includes evaluation of how an individual handles acute problems (e.g., infected cut
on one’s foot or severe chest pain) or practical obstacles (e.g., running out of medi-
cations). Managing financial affairs includes managing one’s bank account or mak-
ing everyday transactions, having an understanding of the importance and role of
money, being aware of and paying routine bills, and a reasoning process for making
financial decisions and reacting to new or unexpected circumstances (e.g., exploita-
tion schemes). These latter two domains demonstrate the equal and robust roles that
both decision-making and executive capacity have on maintaining key functional
domains of safe and independent living.
The clinical assessment of a vulnerable adults’ capacity for safe and indepen-
dent living should include evaluation of decision-making and executive capac-
ity across each of five functional domains for safe and independent living:
• Maintaining personal needs and hygiene (includes bathing, dressing,

mobility and transferring, sleeping, and feeding)
• Condition of the home environment (includes maintenance and the physi-
cal structure of one’s living environment)
• Performing activities for independent living (includes shopping, cooking,
cleaning)
• Health-care self-management (includes medication management, wound
care, self-monitoring glucose levels, attending routine medical appoint-
ment, awareness of acute symptoms)
• Managing financial affairs (includes managing daily transactions, aware-
ness and payment of routine bills, and a reasoning process for making
financial decisions)
ractical Approach to the Assessment of Capacity for Safe

P
and Independent Living
Clinicians should assess capacity when a vulnerable older adult presents with signs
or symptoms similar to those in Mr. Davis’ presentation. These include:
• Frequent hospital or emergency department visits for treatable chronic

conditions
• Frequent falls and injuries
16 A.D. Naik
• Change in physical appearance

• Unexplained weight loss
• Cognitive impairment or disordered thinking
• Depression or generalized anxiety
• Excessive polypharmacy, medication adverse events, and gaps in medication refills
• Missed appointments and poorly controlled blood pressure or glucose despite
medications
• Limited support system and reports to social and/or adult protective services
When these warning signs present with greater frequency or number, clinicians
should undertake a comprehensive assessment to identify specific impairments in
the capacity for safe and independent living and identify specific interventions to
address these gaps. Clinicians can target gaps in decision-making and/or executive
capacity across the five functional domains of safe and independent living.
Assessments should include the use of validated screening instruments and tests
with population-based norms as well as more personalized clinical assessments
including screening for judgment and capacity. Proxy reports and in-home assess-
ments are also useful for gaining a clear understanding of executive capacity across
the five domains. Many of these validated assessment instruments are common to
the practice of geriatrics. We recommend that clinicians start with standardized
assessment instruments as well as individualized clinical evaluations. Proxy reports
and home evaluation should follow, especially if initial assessments fail to provide
definitive understanding of executive capacity. All capacity evaluations should
include individualized assessments of decision-making or judgment as well as strat-
egies to ensure implementation of an agreed upon care plan.
We recommend beginning with standardized assessment instruments that have
well-validated population norms and cut scores that can evaluate each of the following
domains: cognitive function, mood (depression or depression and anxiety), activities
of daily living (basic ADLs and instrumental IADLs or a combined tool such as
Vulnerable Elders Scale-13), mobility screens (timed up and go or formal gait speed),
and nutrition. The classic cognitive function screen is the mini-mental state examina-
tion (MMSE). However, other screening tests, like the St. Louis Mental State
Examination (SLUMS) or Montreal Cognitive Assessment (MOCA), are now favored
due to their greater ability to identify impairments in executive cognitive functions.
Still other cognitive screens, such as the Executive interview (EXIT) and clock-draw-
ing tasks, are more specific screening tools of executive cognitive functions and asso-
ciated with declines in functional status and the capacity to consent to treatment.
Another highly specialized screening tool is the Financial Capacity Instrument (FCI)
which is used to evaluate decision-making and executive capacity for managing one’s
financial affairs and estate and conducting financial transactions. Additional standard-
ized scales, often performed by occupational therapists, can evaluate a vulnerable
older adult’s executive and performance abilities with everyday, independent living
skills. We have previously demonstrated the effectiveness of one such tool, the
Kohlman Evaluation of Living Skills (KELS), in identifying adults with self-neglect-
ing behaviors sufficient enough to be reported to Adult Protective Services [7].
Standardized assessment should always be followed with individual assess-

ments of medical status (i.e., progress note with history and physical) and psycho-
social status (commonly done by social work). Traditional medical examinations
can identify geriatric syndromes that are common contributors to vulnerability,
such as depression, delirium, and dementia, as well as diseases that impact every-
day functions: memory, judgment, mobility, cardiopulmonary status, pain, etc. As
part of the medical and psychosocial assessments, the clinical team should assess
executive function within the context of the five domains of capacity for safe and
independent living. The following are some examples of items that may be
included:
• Personal needs and hygiene: physical examination of the hair, skin, and nails,
gait evaluation, and screening for balance problems and recent falls.
• Condition of the home environment: proxy reports of the home environment or a
home safety evaluation performed by an occupational therapist or home health
service.
• Activities of daily living: ask patient to use the clinic’s phone and call a friend or
other service to ask for a ride (done through actual demonstration).
• Health-care self-management: ask patient to bring all medication bottles from
home, even empty ones. Review medication fill and refill dates and pill counts or
have a home health nurse do a home medication assessment.
• Managing financial affairs: proxy reports of bank statements, uncollected debts,
or bills. Can formally assess performance with routine financial tasks, such as
1- or 3-item transactions, including making change or conducting a payment
simulation using a check and register.
MED-SAIL Instrument
We have previously developed and validated a screening tool for Making and
Executing Decisions for Safe and Independent Living or MED-SAIL [8]. The
MED-SAIL tool was designed with the acknowledgment that remaining indepen-
dent in one’s own home is a primary goal for older adults, capacity for safe and
independent living is threatened with vulnerability and aging, and health-care and
social service providers in the community lack adequate screening tools. The tool
draws from the conceptual and empirical literature in clinical ethics. Numerous
focus groups enrolling community-based healthcare and social services profession-
als guided the design of the instrument and contents of the screening tool.
Specifically, they helped identify scenarios that are intended to provide a sense of
the respondent’s executive capacity across each of the five domains for safe and
independent living. These seven scenarios are as follows:
1. The door to your home is locked and you do not have a key.
2. You run out of a medication you take regularly.
3. You are home and suddenly there is a fire in your kitchen.
18 A.D. Naik
4. You notice that the cut on your foot is not healing and has become infected.
5. Someone calls saying you’ve won $100,000 and all they need from you is your
social security number to verify your identity.
6. You are driving to the grocery store and you get a flat tire.
7. Your heating unit [air conditioner] breaks down and it is very cold [hot]
outside.
The tool follows the structure of the decision-making capacity standards as

developed by Appelbaum and Grisso and described in Table 2.1. These decision-
making capacity standards are then applied conceptually to the specific real-world
scenarios described above. When using the MED-SAIL tool, the clinician typi-
cally works through two to three of the real-world scenarios. Each scenario has
prompts (see Table 2.1) that relate to the standards for decision-making capacity.
Each of the standards are then scored and a total score is calculated. Population
norms and precise cutoffs across a wide range of patient types have not been
developed as of this writing. However, the tool is still of practical clinical use
because clinicians can use MED-SAIL results in conjunction with the other parts
(i.e., the standardized and individualized assessments) of their evaluation of the
vulnerable older adult’s capacity for safe and independent living. The clinical
team may need to make additional referrals (e.g., occupational and physical thera-
pists) when particular healthcare professionals are not part of the immediate team.
Referrals for home-based assessments are particularly common and provide an
important opportunity to evaluate the physical state of the older adult’s home
environment.
Table 2.1 Eliciting standards of decision-making capacity

Standards for decision-making Questions or prompts to
capacity Descriptions of each standard eliciting each standard
Understanding Repeat the simple scenario phrase Please tell me in your
in his/her own words own words what I just
said
Appreciation Assesses respondent’s ability to Would this be a problem
appreciate impact of scenario on for you? Why or why
his/her own life not?
Expressing a choice Assesses respondent’s ability to What would you do in
express choices/plans this scenario?
Problem-solving/ Assesses whether respondent can What would you do if
consequential reasoning perform abstract problem-solving [response to previous
in a new hypothetical situation question] didn’t work?
Comparative reasoning Assesses respondent’s ability to Explain what is good or
compare two options bad about these options
Generate consequences Assesses respondent’s ability to What could you do to
generate ideas on how to prevent prevent this from
the scenario from occurring or happening?
preparing in case it does
I nterventions to Support Capacity for Safe and Independent

Living
We recommend that clinicians create a final summary of all assessments to identify

precise impairments across each of the five functional domains for safe and inde-
pendent living and whether these deficits are in decision-making capacity, executive
capacity, or both. By identifying precise functional impairments, the clinical team
can then identify specific medical, healthcare, and social services interventions that
can be prescribed/recommended to address these impairments. Interventions will
either support the deficits of the vulnerable adult (e.g., treating symptoms of depres-
sion, providing a transfer bench for the bathroom) or reduce the effort needed to
accomplish a task (e.g., engaging a home health nurse to assist with medication
management, designating a proxy for financial affairs). This method of intervention
is more aligned with traditional healthcare services and targets supporting of auton-
omy to live independently before restraining the vulnerable older adult’s autonomy
in the name of safety. However, the range of interventions can be quite varied from
medical to social to legal. We categorize them broadly as:
1. Medical—medication management, disease management, psychiatric treatment

referral, etc.
2. Environment—alternative living arrangement, home health, home safety evalua-
tion, mobility aids, etc.
3. Social support—adult daycare, patient and family education, caregiver support, etc.
4. Community resources—link to community services, link to health insurance
benefits, etc.
5. Legal services—advance directives, APS, power of attorney, representative
payee, etc.
Appointment of a guardian or other legal surrogate decision-maker is a potential

option to avoid subsequent placement in long-term care. Follow-up evaluations can
then be used to determine the effectiveness of the prescribed interventions and the
older adult’s responsiveness to those interventions. The following table provides a
set of treatment suggestions that link different intervention types that might be nec-
essary based on the level of capacity impairment present (Table 2.2).
Conclusion
The local geriatrics clinic conducted a comprehensive geriatric assessment of
Mr. Davis. The clinic confirmed many of the findings of his prior medical evalu-
ations, all pointing to a state of vulnerability. The assessment found evidence for
mild cognitive impairment not outside the range of normal for his age. Mr. Davis
does not have major depression but does report some apathy and occasional feel-
ings of sadness related to his current medical conditions. He requires assistance
for most activities of daily living and has increasing difficulty with personal care
and hygiene. The clinic placed a referral to a physical medicine physician for
evaluation and possible joint injections to reduce pain and improve shoulder
20 A.D. Naik
Table 2.2 Suggested intervention for impaired capacity for safe and independent living
Intervention Full capacity Partial capacity No or limited capacity
Medical Disease Medication Psychiatric referral
management management Assisted medication
Disease management management
Medication therapy
Environment Home Independent living Assisted living
modifications Assisted living Nursing home
Senior apartments Home health 24-h personal care
Independent living Mobility aids Mobility aids
Mobility aids
Social support Senior center Adult day care Adult day care
Volunteering Senior center Activities for stimulation
Caregiver support Respite
group
Community Housekeeping Meals on wheels Meals on wheels
resources Geriatric care Geriatric care manager
manager
Legal services Power of attorney Representative payee Representative payee
Living will Power of attorney Power of attorney
Legal/financial Guardianship
oversight Out-of-hospital DNR
Suggestions provided by Tziona Regev, MSW for the Capacity Assessment and Intervention clinic
at Quentin Meese Community Hospital, Harris Health System, Houston, Texas
functioning with the goal of improving bathing and dressing. His home environ-
ment is stable but requires his daughter and son-in-law’s involvement to remain
at this level. He was found to have difficulties with executive capacity, especially
with managing his medications and finances. While Mr. Davis was resistant to
this finding at first, his difficulties during the evaluation itself seems to have been
a tipping point. He was now willing to allow his family to prepare a pill tray for
his medications, and his son-in-law became his formal power of attorney for
financial decisions (Mr. Davis had a soft spot for a fellow accountant). The fam-
ily also determined that adult day services once or twice a week might be of
interest to Mr. Davis. An occupational therapy consult was also ordered to do a
home safety evaluation and determine if any assistive devices were needed in the
bathroom to further improve function and safety. Mr. Davis and his daughter
agreed to return in 3 months to reassess his status and the success of these inter-
ventions. This capacity assessment and intervention plan will not reverse Mr.
Davis’ vulnerability, but may allow him to remain at home living as indepen-
dently as possible for the immediate future.
References
1. Dyer CB, Pickens S, Burnett J. Vulnerable elders: when it is no longer safe to live alone.
JAMA. 2007;298(12):1448–50.
2. Skelton F, Kunik ME, Regev T, Naik AD. Determining if an older adult can make and execute
decisions to live safely at home: a capacity assessment and intervention model. Arch Gerontol
Geriatr. 2010;50(3):300–5.
3. Moye J, Naik AD. Preserving rights for individuals facing guardianship. JAMA.
2011;305(9):936–7.
4. Faden RR, Beauchamp TL. A history and theory of informed consent. New York: Oxford
University Press; 1986.
5. Naik AD, Dyer CB, Kunik ME, McCullough LB. Patient autonomy for the management of
chronic conditions: a two-component re-conceptualization. Am J Bioeth. 2009;9(2):23–30.
6. Appelbaum PS, Grisso T. Assessing patients’ capacities to consent to treatment. N Engl J Med.
1988;319(25):1635–8.
7. Pickens S, Naik AD, Burnett J, Kelly PA, Gleason M, Dyer CB. The utility of the Kohlman
evaluation of living skills test is associated with substantiated cases of elder self‐neglect. J Am
Acad Nurse Pract. 2007;19(3):137–42.
8. Mills WL, Regev T, Kunik ME, Wilson NL, Moye J, McCullough LB, Naik AD. Making and
Executing Decisions for Safe and Independent Living (MED-SAIL): development and valida-
tion of a brief screening tool. Am J Geriatr Psychiatry. 2014;22(3):285–93.
Surrogate Decision-Making
and Advance Care Planning 3
Ursula K. Braun
Case Presentation
Mr. T is a 78-year-old veteran with metastatic bladder cancer to the bones
and liver who has been hospitalized for >1 month with various complications
from his nephrostomy tubes and infections. His wife of 10 years is at bedside
continuously during the day and gets updated by the physicians regularly. The
patient agrees to a DNR/DNI order during a palliative care consultation. He
is fairly stable at the moment but bedbound and dependent in all ADLs need-
ing total care. No family is able or willing to care for him at home, and he is
transferred to a palliative care unit for comfort care; his wife is very apprecia-
tive of the care there given to him and the emotional support to her. After a
week, two of his daughters visit. The patient has five adult children, three who
live in the larger metropolitan area and two who live far away. The patient
now completes an advance directive in which he names two of his daughters
as MPOA. He does not complete a living will.
The next day, the patient’s daughter (now MPOA) expresses anger that the
patient is receiving hospice care and demands that he be transferred to the
renowned cancer center in town “to be enrolled in clinical trials.” Despite
attempts to attend to her feelings and to explain the patient’s medical condi-
tion, she asks the team to facilitate a “transfer,” but the patient is not accepted
at the cancer center because he is not a candidate for any clinical trials due
to poor performance status. She is not happy with the care he is receiving in
U.K. Braun, MD, MPH

Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E.DeBakey VA
Medical Center, Houston, TX, USA
Division of Geriatrics, Department of Medicine, Baylor College of Medicine,
Houston, TX, USA
Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
e-mail: ursula.braun@va.gov; ubraun@bcm.edu

DOI 10.1007/978-3-319-44084-2_3
Another random document with
no related content on Scribd:
modern would be the gallows, similarly consecrated,) but who
burning with that devotion which led him of old to bear that shameful
burden? His own humble name raised to a place above the brightest
of Roman, of Grecian, of Hebrew, or Chaldean story! but made, alas!
the supporter of a tyranny over souls, far more grinding and
remorseless than any which he labored to overthrow. The fabled
spot of his grave, housed in a temple to which the noblest shrine of
ancient heathenism “was but a cell!” but in which are celebrated,
under the sanction of his sainted name, the rites of an idolatry, than
which that of Rome, or Greece, or Egypt would seem more
spiritual,――and of tedious, unmeaning ceremonies, compared with
which the whole formalities of the Levitical ritual might be
pronounced simple and practical!
These would be the first sights that would meet the eye of the
disentombed apostle, if he should rise over the spot which claims the
honors of his martyr-tomb, and the consecration of his commission.
How mournfully would he turn from all the mighty honors of that
idolatrous worship,――from the deified glories of that sublimest of
shrines that ever rose over the earth! How earnestly would he long
for the high temple of one humble, pure heart, that knew and felt the
simplicity of the truth as it was in Jesus! How joyfully would he hail
the manifestations of that active evangelizing spirit that consecrated
and fitted him for his great missionary enterprise! His amazed and
grieved soul would doubtless here and there feel its new view
rewarded, in the sight of much that was accordant with the holy
feeling that inspired the apostolic band. All over Christendom, might
he find scattered the occasional lights of a purer devotion, and on
many lands he would see the truth pouring, in something of the clear
splendor for which he hoped and labored. But of the countless souls
that owned Jesus as Lord and Savior, millions on millions,――and
vast numbers too, even in the lands of a reformed faith,――would be
found still clinging to the vain support of forms, and names, and
observances,――and but a few, a precious few, who had learned
what that means――“I will have mercy and not sacrifice”――works
and not words,――deeds and not creeds,――high, simple, active,
energetic, enterprising devotion, and not cloistered
reverence,――chanceled worship,――or soul-wearying rituals.
Would not the apostle, sickened with the revelations of such a
resurrection, and more appalled than delighted, call on the power
that brought him up from the peaceful rest of the blessed, to give him
again the calm repose of those who die in the Lord, rather than the
idolatrous honors of such an apotheosis, or the strange sight of the
results of such an evangelization?――“Let me enter again the gates
of Hades, but not the portals of these temples of superstition. Let me
lie down with the souls of the humble, but not in the shrine of this
heathenish pile. Leave me once more to rest from my labors, with
my works still following; and call me not from this repose till the
labors I left on earth unachieved, have been better done. We did not
follow these cunningly-devised fables, when we made known to men
the power and coming of our Lord Jesus Christ, but the simple eye-
witness story of his majesty. We had a surer word of prophecy; and
well would it have been, if these had turned their wandering eyes to
it, as to a light shining in a dark place, and kept that steady beacon
in view, through the stormy gloom of ages, until the day dawn and
the day-star arise in their hearts. These are not the new heavens
and the new earth, wherein dwelleth righteousness, for which we
looked, according to God’s promise. Those must the faithful still look
for, believing that Jehovah, with whom a thousand years are as one
day, is not slack concerning his promise, but desires all to come to
repentance, and will come himself at last in the achievment of our
labors. Then call me.”
What a life was this! Its early recorded events found him a poor
fisherman, in a rude, despised province, toiling day by day in a low,
laborious business,――living with hardly a hope above the beasts
that perish. By the side of that lake, one morning, walked a stranger,
who, with mild words but wondrous deeds, called the poor fisherman
to leave all, and follow him. Won by the commanding promise of the
call, he obeyed, and followed that new Master, with high hopes of
earthly glory for a while, which at last were darkened and crushed in
the gradual developments of a far deeper plan than his rude mind
could at first have appreciated. But still he followed him, through toils
and sorrows, through revelations and trials, at last to the sight of his
bloody cross; and followed him, still unchanged in heart, basely and
almost hopelessly wicked. The fairest trial of his virtue proved him
after all, lazy, bloody-minded, but cowardly,――lying, and utterly
faithless in the promise of new life from the grave. But a change
came over him. He, so lately a cowardly disowner of his Master’s
name, now, with a courageous martyr-spirit dared the wrath of the
awful magnates of his nation, in attesting his faith in Christ. Once a
fierce, brawling, ear-cutting Galilean,――henceforth he lived an
unresisting subject of abuse, stripes, bonds, imprisonment and
threatened death. When was there ever such a triumph of grace in
the heart of man? The conversion of Paul himself could not be
compared with it, as a moral miracle. The apostle of Tarsus was a
refined, well-educated man, brought up in the great college of the
Jewish law, theology and literature, and not wholly unacquainted with
the Grecian writers. The power of a high spiritual faith over such a
mind, however steeled by prejudice, was not so wonderful as its
renovating, refining and elevating influence on the rude fisherman of
Bethsaida. Paul was a man of considerable natural genius, and he
shows it on every page of his writings; but in Peter there are seen
few evidences of a mind naturally exalted, and the whole tenor of his
words and actions seems to imply a character of sound common
sense, and great energy, but of perceptions and powers of
expression, great, not so much by inborn genius, as by the impulse
of a higher spirit within him, gradually bringing him to the possession
of new faculties,――intellectual as well as moral. This was the spirit
which raised him from the humble task of a fisherman, to that of
drawing men and nations within the compass of the gospel, and to a
glory which not all the gods of ancient superstition ever attained.
Most empty honors! Why hew down the marble mountains, and
rear them into walls as massive and as lasting? Why raise the
solemn arches and the lofty towers to overtop the everlasting hills
with their heavenward heads? Or lift the skiey dome into the middle
heaven, almost outswelling the blue vault itself? Why task the soul of
art for new creations to line the long-drawn aisles, and gem the
fretted roof? There is a glory that shall outlast all
“The cloud-capped towers,――the gorgeous palaces,
The solemn temples,――the great globe itself,――
Yea all which it inherit;”
――a glory far beyond the brightest things of earth in its brightest
day; for “they that be wise shall shine as the firmament, and they that
turn many to righteousness as the stars, for ever and ever.” Yet in
this the apostle rejoices not;――not that adoring millions lift his
name in prayers, and thanksgivings, and songs, and incense, from
the noblest piles of man’s creation, to the glory of a God,――not
even that over all the earth, in all ages, till the perpetual hills shall
bow with time,――till “eternity grows gray,” the pure in heart will yield
him the highest human honors of the faith, on which nations,
continents and worlds hang their hopes of salvation;――he “rejoices
not that the spirits” of angels or men “are subject to him,――but that
his name is written in heaven.”
ANDREW.
his authentic history.
The name of this apostle is here brought in directly after his

eminent brother, in accordance with the lists of the apostles given by
Matthew and Luke, in their gospels, where they seem to dispose
them all in pairs; and very naturally, in this case, prefer family affinity
as a principle of arrangement, putting together in this and the
following instances, those who were sons of the same father. The
most eminent son of Jonah, deservedly taking the highest place on
all the lists, his brother might very properly so far share in the honors
of this distinction, as to be mentioned along with him, without any
necessary implication of the possession of any of that moral and
intellectual superiority, on which Peter’s claim to the first place was
grounded. These seem, at least, to have been sufficient reasons for
Matthew, in arranging the apostles, and for Luke in his gospel; while
in his history of the Acts of the Apostles he followed a different plan,
putting Andrew fourth on the list, and giving the sons of Zebedee a
place before him, as Mark did also. The uniform manner in which
James and John are mentioned along with Peter on great occasions,
to the total neglect of Andrew, seems to imply that this apostle was
quite behind his brother in those excellences which fitted him for the
leading place in the great Christian enterprise; since it is most
reasonable to believe that, if he had possessed faculties of such a
high order, he would have been readily selected to enjoy with him
the peculiar privileges of a most intimate personal intercourse with
Jesus, and to share the high honors of his peculiar revelations of
glory and power.
The question of the relative age of the two sons of Jonah, has
been already settled in the beginning of the life of Peter; and in the
same part of the work have also been given all the particulars about
their family, rank, residence, and occupation, which are desirable for
the illustration of the lives and characters of both. So too, throughout
the whole of the sacred narrative, everything that could concern
Andrew has been abundantly expressed and commented on, in the
life of Peter. The occasions on which the name of this apostle is
mentioned in the New Testament, indeed, except in the bare
enumeration of the twelve, are only three,――his first introduction to
Jesus,――his actual call,――and the circumstance of his being
present with his brother and the sons of Zebedee, at the scene on
the mount of Olives, when Christ foretold the utter ruin of the temple.
Of these three scenes, in the first only did he perform such a part, as
to receive any other than a bare mention in the gospel history; nor
even in that solitary circumstance does his conduct seem to have
been of much importance, except as leading his brother to the
knowledge of Jesus. From this circumstance, however, of his being
specified as the first of all the twelve who had a personal
acquaintance with Jesus, he has been honored by many writers with
the distinguishing title of “the first called,” although others have
claimed the dignity of this appellation for another apostle, in whose
life the particular reasons for such a claim will be mentioned.
The first called.――In Greek πρωτοκλητος, (protokletos,) by which name he is called

by Nicephorus Callistus, (Church History, II. 39,) and by several of the Greek Fathers, as
quoted by Cangius, (Gloss. in voc.) Suicer, however, makes no reference whatever to this
term.
From the minute narrative of the circumstances of the call, given

by John in the first chapter of his gospel, it appears, that Andrew,
excited by the fame of the great Baptizer, had left his home at
Bethsaida, and gone to Bethabara, (on the same side of the Jordan,
but farther south,) where the solemn and ardent appeals of the bold
herald of inspiration so far equalled the expectation awakened by
rumor, that, along with vast multitudes who seem to have made but
an indifferent progress in religious knowledge, though brought to the
repentance and confession of their sins, he was baptized in the
Jordan, and was also attached to the person of the great preacher in
a peculiar manner, as it would seem, aiming at a still more advanced
state of indoctrination, than ordinary converts could be expected to
attain. While in this diligent personal attendance on his new Master,
he was one day standing with him upon the banks of the Jordan, the
great scene of the mystic sacrament, listening to the incidental
instructions which fell from the lips of the holy man, in company with
another disciple, his countryman and friend. In the midst of the
conversation, perhaps, while discoursing upon the deep question
then in agitation, about the advent of the Messiah, suddenly the
great preacher exclaimed, “Behold the Lamb of God!” The two
disciples at once turned their eyes towards the person thus solemnly
designated as the Messiah, and saw walking by them, a stranger,
whose demeanor was such as to mark him for the object of the
Baptizer’s apostrophe. With one accord, the two hearers at once left
the teacher, who had now referred them to a higher source of truth
and purity, and both followed together the footsteps of the wonderful
stranger, of whose real character they knew nothing, though their
curiosity must have been most highly excited, by the solemn mystery
of the words in which his greatness was announced. As they hurried
after him, the sound of their hasty feet fell on the ear of the retiring
stranger, who, turning towards his inquiring pursuers, mildly met their
curious glances with the question, “Whom seek ye?”――thus giving
them an opportunity to state their wishes for his acquaintance. They
eagerly answered by the question, implying their desire for a
permanent knowledge of him,――“Rabbi! (Master,) where dwellest
thou?” He kindly answered them with a polite invitation to
accompany him to his lodgings; for there is no reason to believe that
they went with him to his permanent home in Capernaum or
Nazareth; since Jesus was probably then staying at some place near
the scene of the baptism. Being hospitably and familiarly entertained
by Jesus, as his intimate friends, it being then four o’clock in the
afternoon, they remained with him till the next day, enjoying a direct
personal intercourse, which gave them the best opportunities for
learning his character and his power to impart to them the high
instructions which they were prepared to expect, by the solemn
annunciation of the great Baptizer; and at the same time it shows
their own earnestness and zeal for acquiring a knowledge of the
Messiah, as well as his benignant familiarity in thus receiving them
immediately into such a domestication with him. After this protracted
interview with Jesus, Andrew seems to have attained the most
perfect conviction that his newly adopted teacher was all that he had
been declared to be; and in the eagerness of a warm fraternal
affection, he immediately sought his dear brother Simon, and
exultingly announced to him the great results of his yesterday’s
introduction to the wonderful man;――“We have found the Messiah!”
Such a declaration, made with the confidence of one who knew by
personal experience, at once secured the attention of the no less
ardent Simon, and he accordingly gave himself up to the guidance of
the confident Andrew, who led him directly to Jesus, anxious that his
beloved brother should also share in the high favor of the Messiah’s
friendship and instruction. This is the most remarkable recorded
circumstance of Andrew’s life; and on his ready adherence to Jesus,
and the circumstance that he, first of all the disciples, declared him
to be the Messiah, may be founded a just claim for a most honorable
distinction of Andrew.
Bethabara.――Some of the later critics seem disposed to reject this now common
reading, and to adopt in its place that of Bethany, which is supported by such a number of
old manuscripts and versions, as to offer a strong defense against the word at present
established. Both the Syriac versions, the Arabic, Aethiopic, the Vulgate, and the Saxon,
give “Bethany;” and Origen, from whom the other reading seems to have arisen, confesses
that the previously established word was Bethany, which he, with about as much sense of
justice and propriety as could be expected from even the most judicious of the Fathers,
rejected for the unauthorized Bethabara, on the simple ground that there is such a place on
the Jordan, mentioned in Judges vii. 24,――while Bethany is elsewhere in the gospels
described as close to Jerusalem, on the mount of Olives; the venerable Father never
apprehending the probability of two different places bearing the same name, nor referring to
the etymology of Bethany, which is ‫( בית אניה‬beth anyah,) “the house (or place) of a boat,”
equivalent to a “ferry.” (Origen on John, quoted by Wolf.) Chrysostom and Epiphanius are
also quoted by Lampe, as defending this perversion on similar grounds. Heracleon, Nonnus
and Beza are referred to in defense of Bethany; and among moderns, Mill, Simon and
others, are quoted by Wolf on the same side. Campbell and Bloomfield also defend this
view. Scultetus, Grotius and Casaubon, argue in favor of Bethabara. Lightfoot makes a long
argument to prove that Bethany, the true reading, means not any village or particular spot of
that name, but the province or tract, called ♦ Batanea, lying beyond the Jordan, in the
northern part of its course,――a conjecture hardly supported by the structure of the word,
nor by the opinion of any other writer. This Bethany beyond the Jordan, seems to have been
thus particularized as to position, in order to distinguish it from the place of the same name
near Jerusalem. Its exact situation cannot now be ascertained; but it was commonly placed
about fifteen or twenty miles south of Lake Gennesaret.
♦ “Batanaea” replaced with “Batanea”
Lamb of God.――This expression has been the subject of much discussion, and has
been amply illustrated by the labors of learned commentators. Whether John the Baptizer
expected Jesus to atone for the sins of the world, by death, has been a question ably
argued by Kuinoel and Gabler against, and by Lampe, Wolf, and Bloomfield, for the idea of
an implied sacrifice and expiation. The latter writer in particular, is very full and candid: Wolf
also gives a great number of references, and to these authors the critical must resort for the
minutiae of a discussion, too heavy and protracted for this work. (See the above authors on
John i. 29.)
After narrating the particulars of his call, in which he was merely a

companion of his brother, and after specifying the circumstance of
his being present at the prophecy of the temple’s destruction, the
New Testament history takes not the slightest notice of any action of
Andrew’s life; nor is he even mentioned in the Acts of the Apostles,
except in the mere list of their names in the first chapter. For
anything further, reference must be made to that most dubious of
historical materials, the tradition of the Fathers; and the most
reasonable opinion that can be pronounced upon all the rest of
Andrew’s life is, that nothing whatever is known about it. He probably
remained all his life in Palestine, quietly and humbly devoting himself
to the trials and labors of the apostolic life, without reference to the
production of any great admiration of his actions, or to the
perpetuation of his fame. Being older than Peter, he probably died
before him, and perhaps before the last great war of the Jews with
the Romans, ending in the destruction of Jerusalem, which
compelled the Christians to leave the city. He may, however, have
gone eastward with his brother, and passed the last years of his life
in Babylon.
his fabulous history.

But such a simple conclusion to this apostle’s life would by no
means answer the purposes of the ancient writers on these matters;
and accordingly the inquirer into apostolic history is presented with a
long, long talk of Andrew’s journey into Europe, through Greece and
Thrace, where he is said to have founded many churches,
undergone many labors, and performed many miracles,――and at
last to have been crucified in a city of Greece. The brief, but decided
condemnation of all this imposition, however, is found in its absolute
destitution of proof, or of truly ancient authority. Not the most antique
particular of this tedious falsehood can be traced back to a date
within two hundred years of the time of the pretended journey; and
the whole story from beginning to end, was undoubtedly made up to
answer the demands of a credulous age, when, after the triumphant
diffusion of Christianity throughout the Roman empire, curiosity
began to be greatly awakened about the founders of the faith,――a
curiosity too great to be satisfied with the meager statements of the
records of truth. Moreover, every province of Christendom, following
the example of the metropolis, soon began to claim some one of the
apostolic band, as having first preached the gospel in its territories;
and to substantiate these claims, it was necessary to produce a
record corresponding to the legend which at first floated about only
in the mouths of the inventors and propagators. Accordingly,
apocryphal gospels and histories were manufactured in vast
numbers, to meet this new demand, detailing long series of apostolic
labors and journeys, and commemorating martyrdoms in every
civilized country under heaven, from Britain to India. Among these,
the Grecian provinces must needs come in for their share of
apostolic honor; and Andrew was therefore given up to them, as a
founder and martyr. The numerous particulars of fictitious miracles
and persecutions might be amusing, but cannot deserve a place in
this work, to the exclusion of serious matters of fact. A cursory view
of the fables, however, may be allowed, even by these contracted
limits.
The earliest story about Andrew is, that he was sent to Scythia
first, when the apostles divided the world into provinces of duty. His
route is said to have been through Greece, Epirus, and then directly
northward into Scythia. Another later writer however, makes a
different track for him, leading from Palestine into Asia Minor,
through Cappadocia, Galatia and Bithynia;――thence north through
the country of the cannibals and to the wild wastes of
Scythia;――thence south along the northern, western and southern
shores of the Black sea, to Byzantium, (now Constantinople,) and
after some time, through Thrace, southwestwards into Macedonia,
Thessaly, and Achaia, in which last, his life and labors are said to
have ended. By the same author, he is also in another passage said
to have been driven from Byzantium by threats of the persecution,
and therefore to have crossed over the Black sea to city of
Argyropolis, on its southern coast, where he preached two years,
and constituted Stachys bishop of a church which he there founded;
and thence to Sinope in Paphlagonia. It is said by others that, on his
great northern journey, he went not only into Scythia but into
Sogdiana, (now Tartary,) and even to the Sacae, (near the borders of
Thibet,) and to India.
The earliest mention made of the apostle Andrew, by any writer whatever, after the
evangelists, is by Origen, (about A. D. 230 or 240,) who speaks of him as having been sent
to the Scythians. (Commentary on Genesis, 1. 3.) The passage is preserved only in the
Latin translation of his writings, the original Greek of that part having been lost. The date of
the original however, is too late to deserve any credit. A story making its first appearance
nearly two centuries after the occurrence which it commemorates, with no reference to
authorities, is but poor evidence. Eusebius (Church History, III. 1.) mentions barely the
same circumstance as Origen, (A. D. 315.) Gregory Nazianzen (orat. in Ar.) is the first who
says that Andrew went to Greece. (A. D. 370.) Chrysostom also (Homily on xii. apostles)
mentions this. (A. D. 398.) Jerom (Script. Ecc.) quotes Sophronius, as saying that Andrew
went also to the Sogdians and Sacans. (A. D. 397.)
Augustin (the faith against Manichaeanism) is the first who brings in very much from
tradition, respecting Andrew; and his stories are so numerous and entertaining in their
particulars, as to show that before his time, fiction had been most busily at work with the
apostles;――but the details are all of such a character as not to deserve the slightest credit.
The era of his writings moreover, is so late, (A. D. 395,) that he along with his
contemporaries, Jerom and Chrysostom, may be condemned as receivers of late traditions,
and corrupters of the purity of historical as well as sacred truth.
But the later writers go beyond these unsatisfactory generalities,

and enter into the most entertaining particulars, making out very
interesting and romantic stories. The monkish apostolical novelists,
of the fifth century and later, have given a great number of stories
about Andrew, inconsistent with the earlier accounts, with each
other, and with common sense. Indeed there is no great reason to
think that they were meant to be believed, but written very honestly
as fictitious compositions, to gratify the taste of the antique novel-
readers. There is therefore, really, no more obligation resting on the
biographer of the apostles to copy these fables, than on the historian
of Scotland to transcribe the details of the romances of Scott, Porter
and others, though a mere allusion to them might occasionally be
proper. The most serious and the least absurd of these fictions, is
one which narrates that, after having received the grace of the Holy
Spirit by the gift of fiery tongues, he was sent to the Gentiles with an
allotted field of duty. This was to go through Asia Minor, more
especially the northern parts, Cappadocia, Galatia and Bithynia.
Having traversed these and other countries as above stated, he
settled in Achaia. Where, as in the other provinces, during a stay of
many years, he preached divine discourses, and glorified the name
of Christ by wonderful signs and prodigies. At length he was seized
by Aegeas, the Roman proconsul of that province, and by him
crucified, on the charge of having converted to Christianity,
Maximilla, the wife, and Stratocles, the brother of the proconsul, so
that they had learned to abhor that ruler’s wickedness.
This story is from Nicephorus Callistus, a monk of the early part of the fourteenth
century. (See Lardner, Credibility of Gospel History chapter 165.) He wrote an ecclesiastical
history of the period from the birth of Christ to the year 610, in which he has given a vast
number of utterly fabulous stories, adopting all the fictions of earlier historians, and adding,
as it would seem, some new ones. His ignorance and folly are so great, however, that he is
not considered as any authority, even by the Papist writers; for on this very story of Andrew,
even the credulous Baronius says, “Sed fide nutant haec, ob apertum mendacium de
Zeuzippo tyranno,” &c. “These things are unworthy of credit, on account of the manifest lie
about king Zeuzippus, because there was no king in Thrace at that time, the province being
quietly ruled by a Roman president.” (Baronius, Annals, 44. § 31.) The story itself is in
Nicephorus, Church History, II. 39.
One of the longest of these novels contains a series of incidents,

really drawn out with considerable interest, narrating mainly his
supposed adventures in Achaia, without many of the particulars of
his journey thither. It begins with simply announcing that, at the time
of the general dispersion of the apostles on their missionary tours,
Andrew began to preach in Achaia. but was soon after interrupted for
a time by an angelic call, to go a great distance, to a city called
Myrmidon, to help the apostle Matthew out of a scrape, that he had
fallen into of himself, but could not get out of without help. Where in
the world this place was, nobody can tell; for there is a great clashing
among the saintly authorities, whether it was in Scythia or Ethiopia;
and as the place is never mentioned by any body else, they have the
dispute all in their own hands. But since the story says he went all
the way by ship, from Achaia to the city, it would seem most likely to
have been in that part of Scythia which touched the northeastern
border of the Black sea. Having finished this business, as will be
elsewhere told, he went back towards Achaia, and resumed the
good works, but just begun, soon gathering around him a throng of
disciples. Walking out with them one day, he met a blind man, who
made the singular request that the apostle would not restore him to
sight, though confessedly able, but simply give him some money,
victuals and clothes. The acute Andrew straightway smelt a devil,
(and a mighty silly one too,) in this queer speech, and declaring that
these were not the words of the blind man himself, but of a devil who
had possessed him, ordered the foolish demon to come out, and
restored the man to sight, supplying him also with clothes from the
backs of his disciples. The fame of this and other miracles spread far
and fast, and the consequence was that the apostle had as many
calls as a rising quack doctor. Every body that was in any sort of
trouble or difficulty, came to him as a thing of course, to get a miracle
done to suit the case exactly. A rich man who had lost a favorite
slave, by death, had him raised to life by Andrew. A young lad whose
mother had wrongfully accused him, before the proconsul, also
called for help or advice;――Andrew went into court and raised a
terrible earthquake, with thunder and lightning, whereby all present
were knocked down to the ground, and the wicked woman killed.
The proconsul, as soon as he could get up, became converted, with
all who had shared in the tumble. The apostle still increasing in
business, soon had a call to Sinope, to see a whole family who were
in a very bad way,――the old gentleman, Cratinus by name, being
quite sick with a fever,――his wife afflicted with a dreadful dropsy,
and his son possessed with a devil. These were all healed, with
sundry charges about their secret sins, and some particulars as to
the mode of cure, not worth translating, since it reads better in Latin
than in English. He then went on through Asia to the city of Nicaea,
in Bithynia, where his arrival was hailed with a universal shout of joy
from the whole community, who were terribly pestered with seven
naughty devils, that had taken up their quarters among the tombs
close to the highway, where they sat with a large supply of grave-
stones constantly on hand, for no earthly purpose but to pelt decent
people as they went by, and doing it with such a vengeance that they
had killed several outright,――besides broken bones not counted.
Andrew, after exacting from the inhabitants a promise to become
Christians if he cleared out this nuisance, brought out the seven
devils, in spite of themselves, in the shape of dogs, before all the
city; and after he had made them a speech, (given in very bad Latin,
in the story, as it stands,) the whole seven gave a general yelp and
ran off in the wilderness according to Andrew’s direction. The
inhabitants of course, were all baptized; and Callistus was left bishop
over them. Going on from Nicaea, Andrew came next to Nicomedia,
the capital, where he met a funeral procession coming out of the city.
Andrew immediately raised the dead person,――the scene being
evidently copied from that of the widow’s son raised at Nain,
considerably enlarged with new particulars. Going out from
Nicomedia, the apostle embarked on the Black sea, sailing to
Byzantium. On the passage there was occasion for a new
miracle,――a great storm arising, which was immediately stilled by
the apostle. Going on from Byzantium through Thrace, he came
among a horde of savages, who made a rush at him, with drawn
swords. But Andrew making the sign of the cross at them, they all
dropped their swords and fell flat. He then passed over them, and
went on through Thrace into Macedonia.
This story is literally translated from one of the “apostolical stories” of a monk of the
middle ages, who passed them off as true histories, written by Abdias, said to have been
one of the seventy disciples sent out by Jesus, (Luke x. 1,) and to have been afterwards
ordained bishop of Babylon, (by Simon Zelotes and Jude.) It is an imposition so palpable
however, in its absurdities, that it has always been condemned by the best authorities, both
Protestant and Papist: as Melancthon, Bellarmin, Scultetus, Rivetus, the ♦ Magdeburg
centuriators, Baronius, Chemnitius, Tillemont, Vossius, and Bayle, whose opinions and
censures are most of them fully given in the preface to the work itself, by Johann Albert
Fabricius, (Codex apocrypha of the New Testament, part 2.)
♦ “Magdeburgh” replaced with “Magdeburg”
Besides all these series of fictions on Andrew’s life, there are others, quoted as having
been written in the same department. “The Passion of St. Andrew,” a quite late apocryphal
story, professing to have been written by the elders and deacons of the churches of Achaia,
was long extensively received by the Papists, as an authentic and valuable book, and is
quoted by the eloquent and venerable Bernardus, with the most profound respect. It
abounds in long, tedious speeches, as well as painfully absurd incidents. The “Menaei,” or
Greek calendar of the saints, is also copious on this apostle, but is too modern to deserve
any credit whatever. All the ancient fables and traditions were at last collected into a huge
volume, by a Frenchman named Andrew de Saussay, who, in 1656, published at Paris, (in
Latin,) a book, entitled “Andrew, brother of Simon Peter, or, Twelve Books on the Glory of
Saint Andrew, the Apostle.” This book was afterwards abridged, or largely borrowed from,
by John Florian Hammerschmid, in a treatise, (in Latin,) published at Prague, in
1699,――entitled “The Apostolic Cross-bearer, or, St. Andrew, the Apostle, described and
set forth, in his life, death, martyrdom, miracles and discourses.”――Baillet’s Lives of the
Saints, (in French,) also contains a full account of the most remarkable details of these
fables. (Baillet, Vies de Saints, Vol. I. February 9th.)
By following these droll stories through all their details, the life of
Andrew might easily be made longer than that of Peter; but the
character of this work would be much degraded from its true
historical dignity by such contents. The monkish novels and
romances would undoubtedly make a very amusing, and in some
senses, an instructive book; and a volume as large as this might be
easily filled with these tales. But this extract will serve very well as a
specimen of their general character. A single passage farther, may
however be presented, giving a somewhat interesting fictitious
account of his crucifixion.
After innumerable works of wonder, Andrew had come at last to

Patras, a city in the northwestern part of Achaia, still known by that
name, standing on the gulf of Lepanto, famous in modern Greek
history as the scene of a desperate struggle with the Turks, during a
long siege, in the war of Grecian independence. In this city, as the
fable states, then resided the Roman proconsul of the province,
whose name is variously given by different story-tellers; by some,
Aegeas,――by others, Aegeates and Aegeatus, and by others,
Egetes. The apostle was soon called on to visit his family, by a
female servant, who had been converted by the preaching of one of
Andrew’s disciples. She, coming to Andrew, fell at his feet, clasping
them, and besought him in the name of the proconsul’s wife,
Maximilla, her mistress, then very sick with a fever, to come to her
house, that she might hear from him the gospel. The apostle went,
therefore, and on entering the room found the proconsul in such an
agony of despair about the sickness of his beloved wife, that he had
at that moment drawn his sword to kill himself. Andrew immediately
cried out, “Proconsul! do thyself no harm; but put up thy sword into
its place, for the present. There will be a time for you to exercise it
upon us, soon.” The ruler, without perceiving the point of the remark,
gave way, in obedience to the word of the apostle. He then, drawing
nigh the bed of the invalid, after some discourse, took hold of her
hand, when she was immediately covered with a profuse sweat, the
symptoms being all relieved and the fever broken up. As soon as the
proconsul saw the wonderful change, he, in a spirit of liberal
remuneration, which deserves the gratitude of the whole medical
profession, ordered to be paid to the holy man the liberal fee of one
hundred pieces of silver; but not appreciating this liberality, Andrew
decidedly refused to receive any pay at all, not choosing to render
such medical services with the view of any compensation, and would
not so much as look at it,――exciting no small astonishment in the
proconsul by such extraordinary disinterestedness. The apostle then
leaving the palace, went on through the city, relieving the most
miserable beggars lying in the dirt, with the same good will which he
had shown in the family of the ruler. Passing on, he came to the
water-side, and there finding a poor, wretched, dirty sailor, lying on
the ground, covered with sores and vermin, cured him directly, lifted
him up, and taking him into the water, close by, gave him a good
washing, which at the same time served for both body and
soul,――for the apostle at once making it answer for a baptism,
pronounced him pure in the name of the Trinity. Soon after this
occurrence, which gained him great fame, he was called to relieve a
boy belonging to Stratocles, the brother of the proconsul, the apostle
having been recommended to him as a curer of diseases, by
Maximilla and her maid. The devil having been, of course, cast out of
the boy, Stratocles believed, as did his brother’s wife, who was so
desirous of hearing the apostle preach, that at last she took
advantage of her husband’s absence in Macedonia, and had regular
religious meetings in her husband’s great hall of state, where he held
his courts,――quite an extraordinary liberty for any man’s wife to
take with his affairs, behind his back. It happened at last, that the
unsuspecting gentleman suddenly returned, when his wife had not
expected him, and would have immediately burst into the room, then
thronged with a great number of all sorts of people; but Andrew,
foreseeing what was about to happen, managed, by a queer kind of
miracle, to make it convenient for him to go somewhere else for a
while, until every one of the audience having been made invisible
with the sign of the cross, by Andrew, sneaked off unseen; so that
the deceived proconsul, when he came in, never suspected what
tricks had been played on him. Maximilla, being now prevented by
her husband’s return from having any more meetings in his house,
afterwards resorted to the apostle’s lodgings, where the Christians
constantly met to hear him,――and became at last so assiduous in
her attendance by day and by night, that her husband began to grow
uneasy about her unseasonable absences, because he had no sort
of pleasure with her since she had been so given up to her
mysterious occupations, away from him almost constantly. He
accordingly began to investigate the difficulty, and finding that it was
the work of Andrew, who had been teaching the lady a new religion,
which wholly absorbed her in devotion, to the exclusion of all
enjoyment with her family, sent for him, and commanded him to take
his choice between renouncing his troublesome faith, and crucifixion.
But the apostle indignantly and intrepidly declared his readiness to
maintain the doctrine of Jesus Christ, through all peril, and even to
death, and then went on to give the sum and substance of his creed.
The unyielding proconsul however, put him in prison immediately,
where Andrew occupied himself all night in exhorting his disciples to
stand fast in the faith. Being brought the next day before the
proconsul’s tribunal, he renewed his refusal to sacrifice to idols, and
was therefore dragged away to the cross, after receiving twenty-one
lashes. The proconsul, enraged at his pertinacity, ordered him to be
bound to the cross, instead of being nailed in the usual way;――(a
very agreeable exchange, it would seem, for any one would rather
have his hands and feet tied with a cord to a cross, than be nailed to
it; and it is hard to see how this could operate to increase his torture,
otherwise than by keeping him there till he starved to death.) On
coming in sight of the cross, he burst out into an eloquent strain of
joy and exultation, while yet at some distance,――exclaiming as
they bore him along, “Hail! O cross! consecrated by the body of
Christ, and adorned with the pearls of his precious limbs! I come to
thee confident and rejoicing, and do thou receive, with exultation, the
disciple of him who once hung on thee, since I have long been thy
lover and have longed to embrace thee. Hail! O cross! that now art
satisfied, though long wearied with waiting for me. O good cross! that
hast acquired grace and beauty from the limbs of the Lord! long-
desired and dearly loved! sought without ceasing, and long foreseen
with wishful mind! take me from men and give me back to my
Master, that by thee He may receive me, who by thee has redeemed
me.” After this personifying address to the inanimate wood, he gave
himself up to the executioners, who stripped him, and bound his
hands and feet as had been directed, thus suspending him on the
cross. Around the place of execution stood a vast throng of
sympathizing beholders, numbering not less than twenty thousand
persons, to whom the apostle, unmoved by the horrors which so
distressed them, now coolly addressed them in the words of life,
though himself on the verge of death. For two days and nights, in
this situation, in fasting and agony, he yet continued without a
moment’s cessation to exhort the multitude who were constantly
thronging to the strange sight; till at last, on the third day, the whole
city, moved beyond all control, by the miracle of energy and
endurance, rushed in one mass to the proconsul, and demanded the
liberation of the God-sustained apostle. The ferocious tyrant,
overawed by the solemn power of the demand, coming from such an
excited multitude, at last yielded; and to the great joy of the people,
went out to the cross to release the holy sufferer, at the sight of
whose enraptured triumph over pain and terror, the hard-hearted
tyrant himself melted, and in sorrow and penitence he drew near the
cross to exercise his new-born mercy. But Andrew, already on the
eve of a martyr’s triumph, would not bear to be snatched back from
such glories so nearly attained; and in earnest remonstrance cried
out, praying, “O Lord Jesus Christ! do not suffer thy servant, who for
thy name’s sake hangs on the cross, to be thus freed,――nor let me,
O merciful God! when now clinging to thy mysteries, be given up
again to human conversations. But take thou me, my Master! whom I
have loved,――whom I have known,――whom I hold,――whom I
long to see,――in whom I am what I am. Let me die then, O Jesus,
good and merciful.” And having said these things for so long a
time,――praising God and rejoicing, he breathed out his soul, amid
the tears and groans of all the beholders.
Here ends the tale of the fictitious Abdias Babylonius, of which this concluding abstract
is another literal specimen, presenting its most effective part in the pathetic line, as the
former does of its ludicrous portions. The story of Andrew is altogether the longest and best
constructed, as well as the most interesting in the character of its incidents, of all contained
in the book of the Pseudo-Abdias; and I have therefore been more liberal in extracts from
this, because it would leave little occasion for any similar specimens under the lives of the
rest of the apostles.
All this long story may, very possibly, have grown up from a beginning which was true;
that is, there may have been another Andrew, who, in a later age of the early times of
Christianity, may have gone over those regions as a missionary, and met with somewhat
similar adventures; and who was afterwards confounded with the apostle Andrew. The
Scotch, for some reason or other, formerly adopted Andrew as their national saint, and
represent him on a cross of a peculiar shape, resembling the letter X, known in heraldry by
the name of a saltier, and borne on the badges of the knights of the Scottish order of the
Thistle, to this day. This idea of his cross, however, has originated since the beginning of
the twelfth century, as I shall show by a passage from Bernardus.
The truly holy Bernard, (Abbot of Clairvaux, in France, A. D. 1112,) better worthy of the
title of Saint than ninety-nine hundredths of all the canonized who lived before him, even
from apostolic days,――has, among his splendid sermons, three most eloquent discourses,
preached in his abbey church, on St. Andrew’s day, in which he alludes to the actions of this
apostle, as recorded in the “Passion of St. Andrew,”――a book which he seems to quote as
worthy of credit. In Latin of Ciceronian purity, he has given some noble specimens of a
pulpit eloquence, rarely equalled in any modern language, and such as never blesses the
ears of the hearers of these days. He begins his first discourse on this subject with saying,
that in “celebrating the glorious triumphs of the blessed Andrew, they had that day been
delighted with the words of grace, that proceeded out of his mouth;”――(doubtless in
hearing the story of the crucifixion read from the fictitious book of the Passion of St. Andrew,
which all supposed to be authentic.) “For there was no room for sorrow, where he himself
was so intensely rejoiced. No one of us mourned for him in his sufferings, for no one dared
to weep over him, while he was thus exulting. So that he might most appropriately say to us,
what the cross-bearing Redeemer said to those who followed him with mourning,――‘Weep
not for me; but weep for yourselves.’ And when the blessed Andrew himself was led to the
cross, and the people, grieving for the unjust condemnation of the holy and just man, would
have prevented his execution,――he, with the most urgent prayer, forbade them from
depriving him of his crown of suffering. For ‘he desired indeed to be released, and to be with
Christ,’――but on the cross; he desired to enter the kingdom,――but by the door. Even as
he said to that loved form, ‘that by thee, he may receive me, who by thee has redeemed
me.’ Therefore if we love him, we shall rejoice with him; not only because he was crowned,
but because he was crucified.” (A bad, and unscriptural doctrine! for no apostle ever taught,
or was taught, that it was worth while for any man to be crucified, when he could well help
it.)
In his second sermon on the same subject, the animated Bernard remarks furthermore,
in comment on the behavior of Andrew, when coming in sight of his cross,――“You have
certainly heard how the blessed Andrew was stayed on the Lord, when he came to the
place where the cross was made ready for him,――and how, by the spirit which he had
received along with the other apostles, in the fiery tongues, he spoke truly fiery words. And
so, seeing from afar the cross prepared, he did not turn pale, though mortal weakness might
seem to demand it; his blood did not freeze,――his hair did not rise,――his voice did not
cleave to his throat, (non stetere comae, aut vox faucibus haesit.) Out of the abundance of
his heart, his mouth did speak; and the deep love which glowed in his heart, sent forth the
words like burning sparks.” He then quotes the speech of Andrew to the cross, as above
given, and proceeds: “I beseech you, brethren, say, is this a man who speaks thus? Is it not
an angel, or some new creature? No: it is merely a ‘man of like passions with ourselves.’
For the very agony itself, in whose approach he thus rejoiced, proves him to have been ‘a
man of passion.’ Whence, then, in man, this new exultation, and joy before unheard of?
Whence, in man, a mind so spiritual,――a love so fervent,――a courage so strong? Far
would it be from the apostle himself, to wish, that we should give the glory of such grace to
him. It is the ‘perfect gift, coming down from the Father of Lights,’――from him, ‘who alone
does wondrous things.’ It was, dearly beloved, plainly, ‘the spirit which helpeth our
infirmities,’ by which was shed abroad in his heart, a love, strong as death,――yea, and
stronger than death. Of which, O may we too be found partakers!”
The preacher then goes on with the practical application of the view of these sufferings,
and the spirit that sustained them, to the circumstances of his hearers. After some
discourse to this effect, he exhorts them to seek this spirit. “Seek it then, dearest! seek it
without ceasing,――seek it without doubting;――in all your works invoke the aid of this
spirit. For we also, my brethren, with the blessed Andrew, must needs take up our
cross,――yea, with that Savior-Lord whom he followed. For, in this he rejoiced,――in this
he exulted;――because not only for him, but with him, he would seem to die, and be
planted, so ‘that suffering with him, he might also reign with him.’ With whom, that we may
also be crucified, let us hear more attentively with the ears of our hearts, the voice of him
who says, ‘He who will come after me, let him deny himself, and take up his cross, and
follow me.’ As if he said, ‘Let him who desires me, despise himself: let him who would do
my will, learn to break his own.’”

Textbook Ethical Considerations and Challenges in Geriatrics 1St Edition Angela Georgia Catic Eds Ebook All Chapter PDF

Uploaded by

Copyright:

Available Formats

You might also like

Textbook Ethical Considerations and Challenges in Geriatrics 1St Edition Angela Georgia Catic Eds Ebook All Chapter PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Textbook Ethical Considerations and Challenges in Geriatrics 1St Edition Angela Georgia Catic Eds Ebook All Chapter PDF

Uploaded by

Copyright:

Available Formats

Ethical Considerations and Challenges

in Geriatrics 1st Edition Angela Georgia

Research in Deaf Education: Contexts, Challenges, and

Emiratization in the UAE Labor Market Opportunities and

Functional Variations in English Theoretical

Compelling Ethical Challenges in Critical Care and

Geriatrics for Specialists 1st Edition John R. Burton

Algorithmic Governance And Governance Of Algorithms:

Long Term Forensic Psychiatric Care Clinical Ethical

Surgical Decision Making in Geriatrics A Comprehensive

Angela Georgia Catic

Ethical Considerations and

ISBN 978-3-319-44083-5 ISBN 978-3-319-44084-2 (eBook)

Library of Congress Control Number: 2017930971

© Springer International Publishing Switzerland 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

1 Geriatric Epidemiology ������������������������������������������������������������������������������ 1

13 Considerations and Challenges in Information and

Lauren J. Gleason, MD, MPH Department of Medicine, Section of Geriatrics

© Springer International Publishing Switzerland 2017 1

Medical Implications of the Aging Population

Acute Versus Chronic Illness

Dementia, or major neurocognitive disorder, typically occurs in individuals over

and memory, complex attention, executive function, language, perceptual-motor,

Surrogate decision-makers, also referred to as a healthcare proxy or a durable power

Social Implications of the Aging Population

government employee pensions (14 %) [24]. Of note, Social Security comprised

© Springer International Publishing Switzerland 2017 9

Capacity for Safe and Independent Living

this observation as his cognitive impairments were minimal and decision-making

• In the USA, approximately 5 million older adults are exposed to these

Two-Dimension Model of Autonomy and Capacity

• Understanding the basic facts surrounding a decision

Executive capacity—does the vulnerable older adult have the capacity to

The Functional Domains of Safe and Independent Living

For clinicians, it is important to move from theoretical concepts of capacity to practical

• Maintaining personal needs and hygiene (includes bathing, dressing,

 ractical Approach to the Assessment of Capacity for Safe

• Frequent hospital or emergency department visits for treatable chronic

• Change in physical appearance

Standardized assessment should always be followed with individual assess-

The tool follows the structure of the decision-making capacity standards as

Table 2.1 Eliciting standards of decision-making capacity

I nterventions to Support Capacity for Safe and Independent

We recommend that clinicians create a final summary of all assessments to identify

1. Medical—medication management, disease management, psychiatric treatment

Appointment of a guardian or other legal surrogate decision-maker is a potential

U.K. Braun, MD, MPH

© Springer International Publishing Switzerland 2017 23

“The cloud-capped towers,――the gorgeous palaces,

The solemn temples,――the great globe itself,――

Yea all which it inherit;”

The name of this apostle is here brought in directly after his

The first called.――In Greek πρωτοκλητος, (protokletos,) by which name he is called

From the minute narrative of the circumstances of the call, given

♦ “Batanaea” replaced with “Batanea”

After narrating the particulars of his call, in which he was merely a

1 Geriatric Epidemiology �� 1

Medical Implications of the Aging Population

Acute Versus Chronic Illness

Social Implications of the Aging Population

Capacity for Safe and Independent Living

Two-Dimension Model of Autonomy and Capacity

The Functional Domains of Safe and Independent Living

ractical Approach to the Assessment of Capacity for Safe

I nterventions to Support Capacity for Safe and Independent