Transcript Elder Abuse: A Hidden, But Festering Public Health Problem

Ethical Issues in Aged Care:
I. Information Disclosure
II. Informed Consent
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Ethical Issues in Aged Care
I. Information Disclosure
II. Informed Consent
http://www.census2011.gov.hk/flash/dashboards/populationgrowth-db-101-en/population-growth-db-101-en.html
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Hong Kong Population Pyramid
Age
Group
1961
Age
Group
2005
Age
Group
85+
85+
80-84
75-79
80-84
70-74
65-69
70-74
60-64
55-59
50-54
60-64
60-64
55-59
50-54
55-59
45-49
40-44
35-39
45-49
40-44
45-49
35-39
30-34
35-39
85+
80-84
75-79
70-74
65-69
30-34
25-29
20-24
75-79
65-69
50-54
40-44
30-34
25-29
20-24
25-29
20-24
15-19
10-14
5-9
15-19
10-14
5-9
15-19
0-4
0-4
5-9
400 300 200 100
0
100 200 300 400
2033
10-14
400 300 200 100
0
100 200 300 400
0-4
400 300 200 100
Thousand Persons
Thousand Persons
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100 200 300 400
Thousand Persons
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Long life expectancy and Ageing population
-
Expectation of life at birth :
1983
2005
2033
Male
72.3  78.8  82.5
Female 78.4  84.4  88.0
- Ageing of the population
Population of the elderly (65+) :
3.2% (1961)  12.1% (2005)  26.8% (2033)
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Outline:
I. Information disclosure
a. Right to Information; Autonomy
b. Veracity
II. Informed Consent:
a. Elder’s mental capacity
b. Information to be given
c. Freedom in decision-making
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Ethical Principles:
These are
the 3
KEY
principles
for ethical
decision
making
These 2
provide checks
on consistency
Respect for The fundamental principle – respect an individual's
Persons autonomy
Nonmaleficence Simple but important – do no harm!
Beneficence When you are certain that you are doing no harm, is
there anything positive you can do!
Integrity Principle serves as a check on personal consistency.
Justice
Principle serves as a check on social consistency.
Utility
Principle provides a mechanism for choosing
between multiple GOODS.
Pragmatic
principles that
Double-effect Principle helps to distinguish the intended GOOD
may help
from foreseeable BAD.
resolve specific
difficulties.
Beabout & Wennemann, Applied Professional Ethics
A. Right to Information
• Fundamental Human Rights
• Moral doctrine of diagnosis disclosure is
derived from:
– respect for the elder’s autonomy
– beneficence
– should truth-telling become a moral absolute?
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• Views of carers, patients and their peer
• When is it justified to withhold the truth
from an elderly patient?
• Is it justifiable to deceive a patient with
a cover-up story?
• What if the truth could be harmful?
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B. Veracity
• Professional obligation to tell the truth
• Virtue
• Fidelity (imposes obligations implicitly
in a trusting relationship)
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C. Informed Consent/Refusal by Elders
Mental
Capacity
Adequate
Information
Voluntariness
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Mental Capacity:
 All adults are assumed to have capacity,
unless they have an impairment affecting
their mind (e.g. severe stage of dementia).
 The overriding principle is that the
disclosure of confidential information is
made in the best interests of the person
lacking capacity.
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Adequate Information
• The diagnosis
• The treatment plan
• Risks of treatment
• Alternatives available
• Opportunity for clarification
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Voluntariness
Elders should be able to make
his/her own health care decision
at a free will, not under any undue
influence from the doctor, family,
even the next-of-kin.
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Caring and treating elders who lack
capacity:
• Paternalism
- overriding a person’s known preferences
based on the justification that this will benefit
them or avoid harm to them
- easier to justify carrying out life-saving
surgery than routine procedures
Hence, paternalism may be justified when
applied in the elder’s best interests.
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Case 1 for discussion:
Ah Tai, a 68-year-old woman visits her
doctor with complaints of abdominal pain that
is persistent but not extreme.
Investigation reveals that she has metastatic
cancer of the pancreas. The woman has just
retired from a busy professional career, and
she and her husband are about to leave on a
round-the-world cruise that they have been
planning for over a year.
Would you tell her her diagnosis? How do
you justify your ethical grounds?
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Case 2 for discussion:
Chan Kueng, an 82-year-old man is admitted
into hospital with a chief concern of
weight loss, generalized weakness, and a
pulmonary mass revealed in an x-ray.
His family approaches the doctor and asks
that the patient not be told, stating that
in his upbringing in mainland China,
tuberculosis (TB) was considered fatal
and to tell him would be like giving him a
“death sentence.”
Should the family’s request be complied with? How do you
justify your
decision?
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Case 3 for discussion:
Mr. Tam is 66 years old and has been brought
into hospital with unstable angina. He is clearly
worried about why he feels so poorly and what is
going ‘to be done’ to him.
An angiogram is considered the next useful
investigation, but the doctor is concerned that if
Mr. Tam is told about the risks he may become
very anxious, thus precipitating a fatal
myocardial infarction.
To tell or not to tell? How to justify your option with ethical
principles?
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Case 4 for discussion:
Leung has schizophrenia and is convinced that
worms are crawling over his skin. He finds this
extremely distressing.
One treatment that could be tried for him is a
new antipsychotic drug, but this carries an 8%
risk of permanent eye damage.
Should Leung be informed of this risk?
Why?
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References:
 Casas, A.V., (2008). Patients’ right to information: a review of
the regulatory ethical framework. Retrieved on 9 June 2012
from http://www.ub.edu/bid/21/vall3.htm
 Hope, T., Savulescu, J. and Hendrick, J. (2003) Medical Ethics
and Law: The core curriculum. Churchill Livingstone,
Edinburgh.
 Pinner, G. (2000). Truth-telling and the diagnosis of
dementia. British Journal of Psychiatry. 176, pp. 514-515
 Pierce, J. & Randels, G. (2010). Contemporary Bioethics.
New York: Oxford University Press.
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