Presented at a Conference on Palliative Care for Geriatrics organized at KFMC on September 16, 2024, by Prof Omar Hasan Kasule MB ChB (MUK), MPH (Harvard), DrPH (Harvard).
INTER-RELATED CARE
MODALITIES THAT ARE INTEGRATED IN OLD AGE
- Geriatric care focuses on the unique needs of the elderly with focus on health. They need not have specific pathology but have general functional deterioration
- Disability care provides help with difficult tasks needed for daily living,
- Palliative care provides relief from pain and other symptoms; the definition does not assume non-curability
- End of life care (terminal care) is care in the time leading to death. This includes decisions about DNR and Euthanasia.
ETHICAL ISSUES IN GERIATRIC CARE-1: autonomy and
decision making
- Impaired
ability to make informed
decisions;
low capacity and low competence. Progressive dementia is a challenge to
autonomy.
- Advance
statements assure prospective autonomy. They have
to be properly documented and witnessed. The advance directive affects a patient’s choices of treatment.
- Relative proxy decision makers are
relatives who decide for the patient: what they know the patient wants or what
they think is in the best interests of the patient
- Non-relative proxy decision makers in the absence of relatives
ETHICAL ISSUES IN GERIATRIC CARE-2: Definition of
the age of geriatrics
- Is there a distinction between ‘disease’ and ‘physiological changes of aging’? Can we limit intervention to pathological changes and treat palliative changes due to old age?
- At what age does geriatrics start? What about early vs delayed aging?
- . آعمار أمتي ما بين الستين إلى السبعين، وأقلهم من يجوز ذلك.
- الترمذي وابن ماجه عن أبي هريرة
- The origin of the age 65 as the age at which social security pensions would start with no clear scientific basis; some think it was the life expectancy
- The long spectrum of geriatric – palliative care. Where is the transition?
ETHICAL ISSUES IN GERIATRIC CARE-3: Decisions
about care
- The benefit/harm equilibrium is different in the elderly and geriatricians must be cautious. Not treating may be an option
- pharmacokinetics, multi-morbidity, polypharmacy, and frailty determine drug reactions in the elderly
- Elderly patients' hospital admissions
caused by ADRs due to usual doses of medications commonly prescribed for
elderly patients[i].
- Drug overdose in the elderly especially opioids.
ETHICAL ISSUES
IN DISABILITY CARE OF GERIATRIC PATIENTS:
- Discrimination of the elderly: consciously or unconsciously
- Access to special services
- Sensitivity training
for health care workers to understand the physical and
psychological needs of persons with disabilities.
- Extra care to avoid miscommunication because the patients may be over sensitive
- Neglect of acute conditions in persons with many disabilities
ETHICAL ISSUES
IN PALLIATIVE CARE OF GERIATRIC PATIENTS-1:
- Deficient decision-making capacity and competence. Caregivers must respect the patient’s autonomy as long as he is competent.·
- Advance statements or living will, Is it stable over time?
- Proxy decision makers, If the patient is not competent to make decisions, his guardian, wali, will make decisions that the caregivers are bound to respect, a competent patient has a right to choose a proxy decision maker. ? Does the wali take over when the patient is incompetent?
- Decisions on interventions: nutrition, hydration, pain control, infection treatment double effect of analgesics.
ETHICAL ISSUES
IN PALLIATIVE CARE OF GERIATRIC PATIENTS-2:
- Balance between pain control and
social
life,
- ·Requests
for assisted death should be
refused. All forms of euthanasia are forbidden.
- ·Telling the whole
truth
to the
patient
requires
judgment
and balancing
benefits and harm.
- ·Privacy and
confidentiality have to be maintained.
- Can palliative care turn into euthanasia?
DECISIONS FOR
THE TERMINALLY
ILL-1:
- Geriatric care and palliative care progress into terminal illness
- Withhold or withdraw aggressive treatment that has no nett benefit lasting for a reasonable time.
- DNR: Withhold
resuscitation
in case of
cardio-respiratory arrest for
patients
who cannot
get a
net benefit
from CPR and who will succumb again and
must undergo resuscitation.
- Withdrawal of life support for brainstem dead patients
- Withdrawal of life support from patients in irreversible coma: ? futility ? quality of life.
DECISIONS FOR
THE TERMINALLY
ILL-2:
- Is it ethical to knowingly prolong the death process?
- The right to die?
- Decision to donate organs: problematic for geriatric patients since their organs may have deteriorated
DNR ORDERS FOR GERIATRIC PATIENTS-1:
- While still competent geriatric patients can be engaged to discuss anticipated DNR orders. The earlier the better. Many DNR orders end up not being used.
- DNR essentially protects patients against futile interventions
- A
do-not-resuscitate
(DNR) order is a decision
made by
three
physicians including
a disease
specialist
and the
primary
doctor
of the
patient.
The family
must be
informed
of the
decision
but they
cannot intervene in
the decision.
- The
DNR order is made
essentially for
situations in which
resuscitation
is futile and not necessarily
for terminal disease per se.
- The
order
should
specify which procedures
are
included
in the
order:
intubation and
ventilation,
chest compressions, ionotropic
drugs,
gas mask
etc.
DNR ORDERS FOR GERIATRIC PATIENTS-2:
- A do not treat (DNT) order relates to treatment of the primary disease condition like cancer when that treatment is considered futile. It does not reject palliative or disability care.
- The term ‘allow natural death’ is preferable
- DNR orders are suspended during anesthesia
- A general hospital policy on DNR may fail; we need to leave room for situation-based decision making
- Acceptance of DNR may relate to socio economic status and religious attitudes.
PLANNING EUTHANASIA IS FORBIDDEN FOR GERIATRIC PATIENTS - 1
- Competent geriatric patients in good health may ask for euthanasia in anticipation of terminal illness with a lot of pain
- Euthanasia, literally ‘good
death’
is causing the death
of a
terminal
patient
to save him/her from
further
pain
and suffering.
- Active euthanasia is an
act of
commission in which
the physician takes an
action
that results
in the
death
of the
patient.
- Passive euthanasia
is an act
of omission in
which
the physician fails
to take action necessary
to sustain the life
of the
terminal
patient.
- Both
active
and passive euthanasia
are
illegal and healthcare workers who
engage
in them
can be
sued for
homicide.
PLANNING EUTHANASIA IS FORBIDDEN FOR GERIATRIC PATIENTS - 2
- Euthanasia at
the request
of the
patient
and with his informed consent is still considered illegal.
- The
distinguishing
feature of euthanasia is the
intention behind the
action,
sparing
the patient further suffering.
- An
action than
can be
considered euthanasia
can be
deemed
legal of
the intention
behind
it is different.
- Withholding a treatment because it is futile is acceptable but withholding it to hasten the death of the patient to avoid further suffering is passive euthanasia.