10 ETHICAL PRINCIPLES IN GERIATRICS AND LONG-TERM CARE

1. BENEFICENCE

• Do right (“good”) by the patient.
• The physician’s main concern is the welfare of the patient.
• Do what is medically helpful.

2. NON-MALEFICENCE

• Avoiding harm.
• Implement effective non-hospital treatment when possible (due to complications that can arise during hospitalization of elderly patients).
• Withhold diagnostic work-up or treatment when intervention is unlikely to result in meaningful survival or patient well-being.
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3. FUTILITY OF TREATMENT

• Treatment should be consistent with the patient’s (clinically realistic) goals.
• Assess each case individually so as to determine whether treatment would be beneficial.
• Avoid interventions that would not benefit the patient and/or prolong suffering.
• Physician’s role as an educator helps clarify issues.

4. CONFIDENTIALITY

• Complete and absolute confidentiality is the underlying tenet.
• Comply with state laws regarding disclosure to public health authorities and third parties.

5. AUTONOMY AND INFORMED CONSENT

• A patient has the inherent right of self-determination.
• A patient has the right to consent and a right to refuse diagnostic work-up or treatment. This includes protection from unwanted touching.
• A patient has the right to be educated on the pros and cons of a medical decision.
• Although patient/proxy may request care in excess of what is considered good medicine, individual autonomy should not violate the principle of beneficence and force physicians to go beyond appropriate medical intervention.
• Autonomy ceases when a patient’s request breaks the law or jeopardizes public health or safety (eg, smoking in one’s room in a LTC facility).
• A patient has the right and is encouraged to execute an advance directive. The physician’s role as an educator is important in this process. State laws may vary.
• To make autonomous decisions, patients must have capacity pertaining to the complexity of the situation. However, the level of capacity may vary as to the complexity of the decision (refusing to be turned in bed may require less mental capacity than deciding on the pros and cons of a complex operation).
• Surrogate decision making may be used when a patient’s wishes are unknown or unclear or the patient lacks capacity.
• Amount of value placed on the principle of autonomy varies with different cultures. Some cultures may regularly use a surrogate as the decision-maker even if the patient has capacity to decide.

6. PHYSICIAN–PATIENT RELATIONSHIP

• A therapeutic alliance should exist between physician and patient.
• There should be fidelity, trust, confidentiality, and protection from intended harm.
• Physicians have an important role in educating their patients.
• Disclose relationships that may impact patient care or decisions.

7. TRUTH TELLING

• Physicians have a duty to tell the truth and be honest versus incomplete statements of encouragement. This should be integrated into good “bedside” manner and patient support.
• Technical terminology should not obscure truth and fact.
• Communicate an honest estimate of prognosis.

8. JUSTICE

• Distribute resources and treatment in an equitable manner.
• Be fair and lawful
• Use objective decision-making processes, not emotional or subjective ones.

9. NON-ABANDONMENT

• Physicians have a duty to uphold the principle of fidelity—not to abandon the patient after establishing a therapeutic relationship.
• A physician may voluntarily terminate care of a patient after the patient/proxy has been informed and provided with a reasonable amount of time to make other arrangements. The physician may be asked to help with such alternative arrangements
• When there is conflict between a patient/proxy and physician concerning a course of treatment, guidance may be obtained through an ethics committee, ombudsman, and/or Department of Health.

10. LIMITED RESOURCES

• Realize that there are limited health care resources.
• Make decisions and allocate limited health care resources in a nondiscriminatory and objective manner.

Suggested Reading
Buchanan SF. Medical ethics at the millennium: A brief retrospective. Colorado Lawyer 1997;26:141-145.

Cobbs EL. Ethical issues of infectious disease interventions. In: Yoshikawa TT, Ouslander JG, eds. Infection Management for Geriatrics in Long-Term Care Facilities. New York, NY: Marcel Dekker, Inc.; 2002:79-97.

Doty WD, Walker RM. Medical futility. Clin Cardiol 2000;23(2 Suppl 2):II6-II16.

Drane JF, Coulehan JL. The concept of futility. Patients do not have a right to demand medically useless treatment. Counterpoint. Health Prog 1993;74(10):28-32.

Feinsod FM, Levenson SA. Procedures for managing ethical issues and medical decision making. Annals of Long-Term Care: Clinical Care and Aging 1998;6:63-65.

Hurst SA. When patients refuse assessment of decision-making capacity: How should clinicians respond? Arch Intern Med 2004;164:1757-1760.

Kapp MB. Geriatrics and the Law: Understanding Patient Rights and Professional Responsibilities. 3rd ed. Springer Series on Ethics, Law, and Aging. New York, NY: Springer Publishing Company; 1999.

Lantos JD. Futility assessments and the doctor–patient relationship. J Am Geriatr Soc 1994;42:868-870.

Levenson SA, Feinsod FM. Implementing effective ethics decision-making programs. Annals of Long-Term Care: Clinical Care and Aging 1999;7:232-237.

Powers BA. Nursing Home Ethics: Everyday Issues Affecting Residents with Dementia. New York, NY: Springer Publishing Company; 2003:214.

Snyder L. Ethics Manual. Ann Intern Med 2005;142:560-582.