Case Vignette Part 1: Introduction and Ethical Tensions
You are in clinic seeing a longstanding patient, an 87-year-old woman with diabetes, congestive heart failure, hypertension, and mild cognitive impairment. She ambulates using a cane. The patient’s adult daughter accompanies her on this visit. The daughter lives several towns away, and prior to today had not visited for several months. The daughter reports being shocked at the deteriorating condition of her mother’s home. She describes a cluttered house, with trip hazards everywhere and stinking piles of garbage in the kitchen. The patient herself says she has some recent difficulty with her vision, but other than that believes she is doing fine. On examination, her blood pressure is 180/82 mm Hg, and her score on the Montreal Cognitive Assessment (MoCA) is 23/30. Laboratory tests show a HbA1c (glycosylated hemoglobin) of 12.5. A visit by a home nurse confirms the daughter’s concerns about the living situation, also noting that the patient’s medications have been removed from their bottles and placed together in a jar on the dresser. When you meet the patient next, you explain your concerns about her living situation and ability to care for herself. She responds that she’s doing “just fine,” and, “I won’t move into a nursing home!”
ETHICAL ISSUES IN THE CARE OF OLDER ADULTS
Ethical tensions arise in the everyday care of older adults, where there is a high prevalence of dementia and functional dependence. These tensions require that clinicians be familiar with ethical concepts central to the care of older adults. These concepts are often cast as principles (central guidelines), professional codes (responsibilities of an ethical clinician), and virtues (qualities of the good clinician). Tables 21–1 and 21–2 provide descriptions of the major principles and virtues, with examples of how these might operate in the daily practice of caring for older adults.
Table 21–1.Ethical principles. ||Download (.pdf) Table 21–1. Ethical principles.
What This Principle Means
Example Issues and Questions That Illustrate the Ethical Principle in the Context of the Case
Respect for autonomy
Autonomy is Greek for “self-rule.” We should respect people’s right to shape their own lives and make medical care decisions according to their values. Several ethical concepts follow from this principle, including informed consent, freedom from interference/control by others, and freedom from unwanted bodily intrusion (including surgery or life-sustaining treatment). Advance directives, and surrogate decision makers using substituted judgment are extensions of individual autonomy. Clinicians can enhance patient’s autonomy by making sure that clinicians know their patient’s goals, values, and preferences, and making sure that patients (or their proxies) understand care options and consequences.
Respect for persons is a related principle, and includes treating people as worthy of respect, dignity, and compassion, even if they lack the decision-making capacity necessary to form autonomous preferences.
Goals and values discussions—”When you think about where you want ...