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Case Vignette

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 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!”

You reiterate your concerns about the home environment. You say to her, “to make sure I’ve done a good job explaining my concerns, can you tell me what I’m worried about?” In her response, she clearly indicates understanding, acknowledging that her home environment is full of fall hazards and that she needs assistance with her medications. However, she reiterates her long-held preference for remaining in her home despite these risks. You decide that she has the capacity to make this decision. She agrees to a family meeting with her daughter and a social worker to discuss how she might receive more support at home.

After a family meeting with you, a social worker, the patient, and her daughter, the patient enrolls in a Program of All-Inclusive Care for the Elderly (PACE). This PACE program allows her to live at home at night and receive comprehensive service at a day center. A home health aide visits her weekly and the daughter pays for a housecleaner.

Ethical Issues in the Care of Older Adults

The high prevalence of cognitive impairment, dementia, and functional dependence raise ethical issues in the everyday care of older adults. These tensions require that clinicians be familiar with ethical issues that are central to the care of older adults. These issues are often cast as principles (central guiding concepts) or virtues (qualities of the good clinician). Tables 12–1 and 12–2 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 12–1.Ethical principles.

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