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What is the ethical position ?. Ageism in Medical Treatment.
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1. Ethical Issues in the Older Surgical Patient:A Lawyers Perspective Barry Speker
barryspeker@samuelphillips.co.uk
2. What is the ethical position ?
3. Ageism in Medical Treatment Where age is an indicator of benefit or risk, age discrimination is appropriate NIHCE 2005
The elderly should be refused operations if they are unlikely to live long enough to enjoy the benefits- one-third of medics surveyed by The Doctor Jan 2008
Older patients less likely to receive treatment to prevent stroke National Audit of stroke units 2004
41% of elderly patients clinically eligible for aortic valve replacement surgery were denied the operation on 3year survival guidelines Heart Journal
4. Unfair on the Elderly It is outrageous to say that older people should miss out on important treatment simply because of their age. All too often people are treated like second class citizens, denied their basic dignity and access to important services.
Gordon Lishman, Director-General, Age Concern
5. Superficial Justification Elderly people are sick more often than younger people
The elderly suffer more from being in end stage of chronic progressive degenerative diseases
The elderly may lack the capacity to make critical decisions
The elderly may be less demanding of treatment
They may not have persuasive advocates
6. Principles of Medical Ethics Beneficence and Non-beneficence
Do good and dont do harm
Autonomy
Patients with capacity have the right to make healthcare decisions about their own bodies
Justice
Fair allocation of limited health resources?
Respect for the sanctity of human life
Differing religious views, relevance of human rights, when does treatment become futile? Who decides best interests?
7. 1 Beneficence and Non-Malfeasance Calculating cost/benefit analysis more complex
Harm more likely; benefit less certain
Additional disadvantages to elderly of hospitalisation confusion, disruption to daily life, risk of falls
Post-operative problems, higher risk of cognitive impairment after major surgery, DVTs
Consider goals of surgery realism about risks and complications Just live with it?
Enable patient to make real and informed decisions telling the whole truth ?
8. 2 Autonomy Facilitate autonomy Mental Capacity Act 2005
Do not make assumptions avoid stereotypes
Beware greater tendency of elderly to acquiesce
Over-reliance on judgement of clinicians
What would you do Doctor? What if it was your Dad?
Advance Directives Validity, Clarity, Relevance
Proxies acting in patients interests? Ulterior motives
Undue influence relatives, carers, religious groups
Patients previous statements. High evidential burden
Has enough time been spent with patient, relatives, other clinicians, GP demotivation from poor prognosis
9. 3.Justice Health Economics
Utilitarian Approach resources to do the most good for the most people
How judged? How to help the most people?
Too simplistic
NICE too fixed on VFM/ saving money?
Idealistic Approach - help the people who need it most
Elderly need disproportionately more healthcare
Would society stand for this?
Realistic Compromise To try to fairly allocate to benefit the largest number and the largest numbers using evidence base
Note: The Courts will not intervene to challenge NHS allocation of resources, provided a recognised procedure has been followed and the decision is not bizarre
10. 4 Sanctity of Human Life Human Rights Act 1998 Art 2 Right to Life; Art 3 No inhuman or degrading treatment; Art 8 Respect for private and family life - Dignity
No right to demand particular health treatment
No euthanasia
Suicide Act
Hippocratic tradition, Christian, Jewish, Muslim views
Omissions withholding/withdrawing, but acts?
Dr Cox well intentioned; Dr Harold Shipman
Double effect
The Diane Pretty Case 2002 no immunity for Mr P
The Reginald Crew Case 2003 no prosec of Mrs C
Do not strive officiously to keep alive
11. Law?
Ethics ?
12. Legal or Ethical? Law should be ethical
Can not conform to the ethics of all
Conjoined twins, stem cell research, savour siblings, abortion, transplantation
Breach of law- criminal prosecution, professional and other discipline, civil claim, publicity
Breach of ethics professional and other discipline, civil claim,publicity,complaints
13. Complex Decision Making Multi-Disciplinary Teams
Protocols
Guidelines of BMA, Royal Colleges, End of Life Decisions BMA 2007
Learning from Audit
Peer Review
Advice from Trust Solicitor
Ethics Committee
Full record in the notes
14. Assessment
15. Pre-Operative Assessment of the Elderly for Surgery Age not good sole predictor of surgical risk
Physiological age-related changes increase risk of surgery and anaesthesia
Co-morbidities increase with age
Aim of asst to integrated response which are clinically reduced or have failed and to review individual organ systems for functional reserve:
Chest disease common in elderly;ischaemic heart disease;pulmonary complications;re-establishing mobility-b/p-DVT;increased delirium,confusion,risk of post-operative cognitive impairment argues against GA and sedation;renal insufficiency
Assessment for emergency surgery with no full evaluation and danger of assumptions
16. Withholding or Withdrawing Treatment Sanctity of Life Autonomy
GMC Guidelines 2008
www.gmc-uk/guidance/current/library/withholding_lifeprolonging_guidance.asp
Modern methods to prolong life include CPR, renal dialysis, artificial ventilation, ANH, inotropic support . But life has a natural end. Ethical dilemmas:
How long to continue?
Has life become futile?
Does continuing active treatment offend patients dignity?
How does doctor respect sanctity of life when limiting supportive treatment?
Sufficiently weighing the views of patient, healthcare team, relatives, carers
How to decide what is under-treatment or over-treatment towards end of life
What is an acceptable quality of life?
A difference between ethically acceptable and legally permissible
17. CPR DNAR Autonomy
Justice
Sanctity
Joint Statement from BMA, Resuscitation Council (UK) and the RCN 2007
All Trusts must have policies
Presumption in favour of CPR if DNAR not recorded
Ageism not acceptable test
Consent/Assessment of competence/Advance Directives/proxies
Decision by most senior clinician but can be delegated
Experienced nurses included
Regular review
18. Legal Position Doctor has duty of care to protect human life and provide Bolam standard of care. No absolute duty to prolong life at all costs
No absolute obligation to provide treatment demanded clinical judgement/resources Leslie Burke Case
Withholding/Withdrawing may be lawful within guidelines
Positive acts to end life are unlawful Dr Cox, Dr Shipman, Diane Pretty
Competent patients can refuse appropriate treatment even if this is bizarre.
No obligation to continue treatment if futile.
Clear indication from competent patient must be respected.
Permissible to consider whether quality of life with or without treatment would be burdensome rather than beneficial.
Responsibility rests with doctor to determine which treatments are in patients best interests.
In cases of doubt application to Court for declaration of lawfulness.
Always consider whether Human Rights Act relevant approach should be proportionate.
19. CONCLUSION Decisions on treatment are multifaceted bringing into account legal and ethical considerations.
Special issues apply in deciding upon anaesthesia and surgery for the elderly patient.
Adverse implications for clinicians where unethical decisions are made.
With the increasing elderly population a greater awareness of and respect for the interests of elderly patients will be essential.
20. QUESTIONS?