ETHICAL & PRACTICAL ISSUES IN THE ELDERLY

1. ETHICAL & PRACTICAL ISSUES IN THE ELDERLY Dr. Angela M. Campbell Lourdes Medical Association Conference RCPSG 1st February 2014

2. WHAT IS GERIATRIC MEDICINE ? • “ Geriatric Medicine is a whole person specialty. Based on a solid infrastructure of general medicine , it involves consideration of psychological , social and spiritual dimensions , together with functional and environmental assessments. A Geriatrician needs to be aware of legal aspects – capacity and consent , human rights , guardianship ; and ethical conundrums , such as when to investigate or treat ” Prof. G. Mulley : A career in Geriatric Medicine ( BGS Newsletter August 2007 )

3. THE ELDERLY IN SOCIETY • Demographic changes - the very elderly, over 85s , are the fastest growing section of society • Health economic implications – increasing need and cost of health and social care for the frail elderly population • Changing role of the elderly in society – contribution and quality of life

4. PRINCIPLES OF MEDICAL ETHICS • Autonomy – authentic “ self-determination ” influenced by information given , cognition , mood , and personal versus societal values • Justice – “ fair ” allocation of health and social care resources based on need and without discrimination • Beneficence – “ do good ” • Non-maleficence – “ do no harm ”

5. ETHICAL CHALLENGES IN GERIATRIC MEDICINE • Witholding and withdrawing treatment e.g. enteral nutrition , CPR • Consent and mental capacity • Advanced directives • Euthanasia ( “ a good death ” )

6. WHAT IS MENTAL CAPACITY ? • An adult is “ capable ” if he or she has : • Received information to make a decision • Is not under pressure from someone else • Can communicate the decision • Consistently holds to this decision

7. WHAT IS MENTAL INCAPACITY ? • An adult is “ incapable ”if he or she : • Cannot act or make decisions or communicate decisions or understand decisions or retain memory of the decision - because of mental disorder or inability to communicate • Not all or none • May be capable of certain types of decisions but not others

9. AWISA ( 2000 ) & MENTAL CAPACITY ACT ( 2005 ) - GENERAL PRINCIPLES • Benefit the adult • Take account of adult`s past and present wishes • Take account of views of relevant others • Use the least restrictive power possible • Adult must be encouraged to use existing skills

10. AREAS COVERED • Decisions about a) money and property b) health and welfare c) both • Intervention order - covers single issue e.g. property sale • Guardianship order - covers long-term needs e.g. in dementia

11. GUARDIANSHIP • 2 doctors` reports confirming incapacity • Mental Health Officer report ( if welfare ) • Relevant adult ( if financial only ) • Granted by a sheriff and registered by the Public Guardian • Usually for 3 years but may be indefinite

12. CURRENT USE • Many elderly in institutional care are incapable – certificate and treatment plan reviewed annually ( now every 3 years if established incapacity ) • Emergency treatment exempt but must consult proxy for other interventions e.g. elective surgery , enteral nutrition , antibiotics • Proxy decision makers may be formal welfare guardian or informal e.g. NOK

13. GUIDANCE ON ETHICAL ISSUES • Hippocratic Oath e.g. “ no intentional killing by act or omission ” • Professional bodies e.g. BMA, GMC , BGS • “ Decisions relating to cardiopulmonary resuscitation : a joint statement ” BMA , Resuscitation Council ( UK ) , RCN ( 2007 ) • “ Treatment and care towards the end of life : good practice in decision making ” GMC ( 2010 ) • Theological guidance e.g. CTS 2010

15. GMC GUIDANCE : END OF LIFE CARE • “ Good end of life care helps patients with life-limiting conditions to live as well as possible until they die , and to die with dignity ” • End of life conditions – progressive conditions , organ or systems failure , acute catastrophic events , PVS • Most difficult decisions are often around starting or stopping potentially life-prolonging treatments – benefit versus burden of care

16. GMC GUIDANCE : ETHICAL PRINCIPLES • Based on Human Rights Act ( 1998 ) • Presumption in favour of prolonging life • Offer treatments where possible benefits outweigh any burdens or risks • Avoid treatments which will not work , provide no overall benefit or have been refused by a competent patient • If patient incompetent must consult Welfare POA / Guardian / Advocate , healthcare team and take into account e.g. advance directive

17. GMC GUIDANCE : CLINICAL JUDGEMENT • Refer to relevant clinical guidelines for specific conditions • Seek opinion of relevant specialist • Communicate effectively with patient or relevant others to ensure realistic understanding of expected outcome and benefits , burdens and risks of interventions • If patient incompetent and there is uncertainty about overall benefit treatment should be started , reviewed and later stopped if ineffective or too burdensome • Ethically witholding and withdrawing treatment are the same but the latter is often emotionally more difficult – this should not affect clinical judgement • Resource constraints may be an issue

19. GMC GUIDANCE :CLINICALLYASSISTED NUTRITION & HYDRATION ( 1 ) • Need to assess patient`s nutritional and hydration status and ensure that this is optimised where possible via the oral route • In patients unable to maintain adequate nutrition and hydration status orally options include IV or S/C fluids , NG , or RIG / PEG feeding • “ The current evidence about the benefits and burdens of these techniques in treating and managing patients towards the end of life is not clear cut ”

20. ACUTE STROKE Dysphagia common but usually resolves within a month Severe stroke and persistent dysphagia has high mortality PEG / RIG superior to NG DEMENTIA Dysphagia versus food refusal Mortality at 1 year 87% ( in stroke 56% ) Meta-analysis showed no significant benefit ENTERAL FEEDING

21. GMC GUIDANCE : CLINICALLY-ASSISTED NUTRITION & HYDRATION ( 2 ) • If these might prolong a patient`s life then treatment should be offered • “ Where a patient`s death is not imminent but their condition is severe and the prognosis very poor you may consider that clinically-assisted nutrition and hydration , while likely to prolong their life , will cause them suffering which could be intolerable ” • “ You must seek a second or expert opinion from a senior clinician……..You should also consider seeking legal advice ”

23. EUTHANASIA “ A GOOD DEATH ” • Killing is murder and assisting suicide a criminal offence • A competent patient can refuse treatment • Treatment of an incompetent patient should be in their best interest.This may be by witholding burdensome treatment or providing palliative treatment that could shorten life – “ doctrine of double effect ” • “ Burden ” of care versus sanctity of life • “ Slippery slope ” - a right to die or a duty to die ?

24. LIVERPOOL CARE PATHWAY

25. LIVERPOOL CARE PATHWAY • ICP designed to manage the care of a person in the last days or hours of life - facilitates MDT communication / documentation • Criteria for use – possible reversible causes for current condition have been considered ; MDT agreed that patient is dying ; 2 of following apply : bedbound , semi-comatose , unable to take sips of fluid , no longer able to take tablets

26. LCP – ANTICIPATORY PRESCRIBING • Pain – Morphine • Nausea – Levomepromazine • Agitation – Midazolam • Excess respiratory secretions – Hyoscine butylbromide

27. LCP - CONTROVERSY • Care or neglect ? • “ Pathway to death ” • Hospice vs acute hospital setting • Diagnosis of “ dying ” • Ethical principles • Training & audit

28. 10 KEY LCP MESSAGES • LCP is only as good as those who use it • LCP should not be used without education & training • Good communication is pivotal to success • LCP neither hastens nor postpones death • Diagnosis of dying should be made by the MDT • LCP does not recommend use of deep continuous sedation • LCP does not preclude “ artificial ” hydration • LCP supports continual reassessment • Reflect , audit , measure & learn • Stop , think , assess , change

29. NEUBERGER REPORT ON THE LCP “ MORE CARE LESS PATHWAY ” JULY 2013 • Nutrition & hydration in the last days and hours of life • Recognising the uncertainty of the diagnosis of dying • Communication with patients and families and between staff

30. INTERIM GUIDANCE :CARING FOR PEOPLE IN THE LAST DAYS & HOURS OF LIFE ( KEY PRINCIPLES ) NHS SCOTLAND DECEMBER 2013 • Communication • MDT discussion and decision making • Address physical , psychological , social and spiritual needs • Consider needs of relatives and carers

31. ISSUES ON PILGRIMAGE TO LOURDES • Elderly – assess co-morbidities , function and cognition , capacity , polypharmacy and medication administration • Management of symptoms – prior to travel on pilgrimage seek advice / care plan from local Palliative care team • Consider and discuss potential impact of journey and pilgrimage on symptoms • Clarify insight of pilgrim and their relatives on prognosis and establish if there is an ACP • Insurance cover - implications of change / deterioration in condition and of hospitalisation in France