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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #1, #4, #6, #7, #22, #37, #45


Learning Objectives

  • To understand the modern legal and ethical framework of clinical decision making

  • To describe how and why decision making is different and more challenging for older adults

  • To recognize the importance of incorporating patients’ and families’ outcome goals as the drivers of medical decision making

Key Clinical Points

  1. The patients’ and families’ perspectives, goals, and values should be the major drivers of medical decision making.

  2. Age-related changes, multifactorial symptoms, changing accuracy of diagnostic tests, changing patient goals, and family perspectives all sum in making decision making more challenging for older adults.

  3. The history and physical should include a detailed assessment of the person’s social/living situation, functional status, mood, and cognition.

  4. Ascertainment of patients’ preferences, which are known to vary among older patients and patients with multiple health conditions, should occur early and often.


Any discussion of decision making must begin with a discussion of the importance of perspective. All decisions are viewed through the lens of the decision maker. In medicine, decisions can be viewed from many perspectives including the patients, the clinicians, the health care system, and even society. This array of lenses with differing motivations and incentives can lead to widely disparate decisions. For example, a doctor may recommend an expensive medication such as a new chemotherapy in the interest of helping a patient live longer. The patient on the other hand may not be singularly focused on survival and/or may find the side effects intolerable. The health care system in which the physician works may be eager to reap the reimbursements of an infusion associated with the medicine. Meanwhile, society may be concerned that the high costs and marginal benefits of medications such as this provide relatively little value to the society as a whole.

This chapter is not meant to be an exhaustive discussion of the science of decision making. As such, a detailed discussion of the contemporary politics and economics of cost-effectiveness, insurance design, cost-sharing, and other issues essential to understanding decision making at the health care system or societal level are beyond the scope of this chapter. Rather, this chapter will take a clinical perspective focusing on the challenges and opportunities for clinicians, patients, and others involved in the complicated evaluation and management of decision making with older adults.


Modern medical decision making sits largely on an ethical foundation. Grounded firmly on the ethical principle of autonomy, emphasis on a patient-centered approach has been rising since the early twentieth century when courts began charging physicians with battery for performing operations to which patients did not consent. While judges have softened this to negligence ...

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