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Medical Ethics in the Elderly

Medical Ethics in the Elderly. Arnold Deering. Prognosis. 1: Adverse prognostic indicators Unconsciousness on admission. Severe co morbidity. Very advanced age. Cognitive impairment. Pre-existing dependence. Prognosis. 2: Aetiology of the stroke

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Medical Ethics in the Elderly

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  1. Medical Ethics in the Elderly Arnold Deering

  2. Prognosis • 1: Adverse prognostic indicators • Unconsciousness on admission. • Severe co morbidity. • Very advanced age. • Cognitive impairment. • Pre-existing dependence.

  3. Prognosis • 2: Aetiology of the stroke • Intracerebral haemorrhages confer a worse prognosis than cerebral infarction. • The mortality at one month following a bleed approaches 50% compared to 15% for infarction.

  4. Prognosis • 3: Site of stroke damage: • Total anterior circulation stroke • 4% independent at 1 year • Partial anterior circulation stroke • 55% independent at 1 year

  5. Prognosis • 4: Scoring scales • Scoring scales have proved accurate in assessing the prognosis when applied between two and four weeks after a stroke. • A [NIHSS] National Institute of Health Stroke Scale score higher than 16 at one week implies a poor prognosis while one below 6 implies a good prognosis.

  6. Early days • Only in a minority of stroke patients is it possible to state that their prognosis is virtually hopeless within the first few days. • All patients other than those with no chance of recovery should receive nutrition and hydration • Other potentially lifesaving treatments [eg antibiotics] should not be withheld while the prognosis is uncertain.

  7. CT scanning • Refusal to perform a CT scan on the grounds of age or disability is unethical. • All patients should have basic investigations except in cases where death is imminent and undertaking investigations is likely to cause distress.

  8. Advance directive • Drawn up by a mentally competent adult • Consequences of refusing treatment understood • The directive was intended to apply to the circumstances that have arisen • It was not made under the influence of any other person

  9. Advance directive • It has not been revoked • The person is now incompetent of making a decision • There is no statute law enforcing the content of a directive

  10. Enduring Power of Attorney • Covers financial matters not medical or non financial personal matters

  11. Artificial feeding • Objectives • To prolong life? • To create health? • To prevent disease? • To palliate terminal illness?

  12. Artificial feeding • Can nutrition achieve the objectives for any patient? • Can nutrition achieve the objectives for this patient?

  13. Artificial feeding • Basic right? • Medical therapy?

  14. Key Legal issues • Food is legally identified by its chemical composition not by its form of administration. • Liquid food does not therefore constitute medicine. • Artificial feeding does however form part of a regimen which amounts to medical treatment.

  15. Key Legal issues • Medical treatment generally may not be administered to a competent adult without their consent. • In the case of incompetent adults, feeding decisions should follow their best interests.

  16. Key Legal issues • Assessment of best interests usually includes discussion with family members. • There is no obligation to give treatment that is futile or excessively burdensome. • The law regards withholding or withdrawing treatment as an “omission” not an “act” – “letting die” rather than “killing”.

  17. Do Not Attempt Resus. order • It is acceptable to issue a DNAR order while continuing all other treatments. • It is unacceptable to issue a DNAR order to a patient solely because they have had a stroke.

  18. Antibiotics • To withhold antibiotics from a patient who has a 5% chance of recovery may be ethical – to do the same in a patient with a 50% chance of recovery certainly is not.

  19. Consent • Legally no adult can either give or withhold consent for any procedure on behalf of another adult. • The final responsibility for health care decisions rests with the Consultant and the Multi-Disciplinary Team who must act in the patient’s best interest

  20. Withdrawal of treatment • If one regards nutrition via tube feeding as a medical intervention then if the indication for such an intervention no longer exists, that intervention can be withdrawn.

  21. Conclusion • Difficult decision are commonplace • Communication with patients and relatives at all stages is the best way to make sure acceptability of decisions.

  22. The end!

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