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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #4, #5, #27, #46


Learning Objectives

  • Discuss the steps in the CASES approach and how it is used to address ethical dilemmas.

  • Define moral distress and identify risk factors for developing it.

  • Explain the steps in the SPIKES approach to breaking bad news.

  • Review the pros and cons of advance care planning (ACP), advance care directives, POLST forms, and goals-of-care discussions.

  • Understand the need for surrogate decision making to ensure appropriate care of many older adults.

  • Explore the concepts of substituted judgment versus best interest.

  • Recognize how an incapacitated patient’s legal decision maker is identified.

  • Gain insight into the experience of surrogate decision makers and potential for surrogate distress after making difficult medical decisions.

  • Describe the indications for palliative sedation.

  • Recognize the barriers to cessation of driving.

  • Discuss examples of ethical dilemmas that arise in nursing homes when the desire to maintain quality-of-care indicators is in conflict with promoting patient preferences and quality end-of-life care.

Key Clinical Points

  1. Health care professionals who work with older patients may encounter ethical dilemmas which arise out of conflicts in values about the right thing to do.

  2. Patients with decisional capacity have the right to make decisions that their medical teams and families don’t agree with.

  3. Moral distress is a condition in which clinicians feel forced to provide care they believe is wrong, which can lead to burnout and to them leaving their jobs and professions.

  4. The majority of people want to be told if they have dementia.

  5. By participating in ACP and completing advance directives, people can identify preferred surrogate decision makers, and provide guidance to those decision makers about their goals and care preferences for future care if they lose decisional capacity.

  6. Making medical decisions for loved ones can be very stressful for surrogate decision makers and even lead to posttraumatic stress disorder.

  7. Most states and the Veterans Administration (VA) have laws designating a legal hierarchy of surrogates.

  8. Through a process of shared decision making, patients or their surrogates share information about their goals and care preferences with clinicians, and their clinicians share pertinent medical information and make care recommendations based on the patient’s values and goals.

  9. Palliative sedation is a legal intervention of last resort to promote relief of intractable suffering for terminally ill patients who have comfort as their primary goal of care.

  10. Physician aid in dying (PAD), also called physician-assisted suicide, is legal in some US states and countries. Euthanasia is not legal in the United States, but is legal in Belgium and the Netherlands.

  11. Patients may raise the topic of PAD as a way to begin a conversation about the end of life. Clinicians should view this as an opportunity to talk about sources of intractable suffering and fears about dying regardless of whether or not they live in a state where the practice is legal.

  12. Questions about whether or ...

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