Ethical Considerations for the Aging

Question

Answer

The University of Washington, Department of Bioethics provides some great information on ethics and ethical considerations. They state that there are four topics by which every ethical problem should be judged: 1) medical indications, 2) patient preferences, 3) quality of life, and 4) contextual features, which can be social, economical, or legal.

Medical Indications

Medical indications should be used as part of our decision-making rubric. We look at the medical facts. What is the patient's diagnosis? What comorbidities exist?  With that diagnosis and the comorbidities, what is the prognosis for that patient if that disease process is normal? Obviously, no two patients are absolutely the same, and therefore a prognosis or prognoses are somewhat subjective. But usually there are some averages or some norms.  What are the available interventions?  What is the true purpose of the medical intervention and why are we doing it?

Patient Preference

Another important consideration is patient preference. One of the first questions we should ask every patient is, “What are your goals for this treatment, for this therapy or for this procedure? What do you want?”

We know that there may be some risks with any procedure or any treatment. Even outside the realm of speech-language pathology, there may be risks to a treatment.  But the patient has to decide if the risk is worth the benefit. It is not uncommon for an elderly patient who has a fracture, for example, that the physician says, "We're not going to do surgery because the risk of surgery outweighs the benefit of the surgical intervention."  It is important to talk to the patient and get their preferences and their assessment of whether or not they believe a procedure is worth the risk.

Ethical questions that should always be asked include:

1. Is the patient competent to make a decision? Some patients may not have the mental capacity, whether it is from some type of traumatic brain injury, stroke, a progressive illness such as dementia, or a major, underlying cognitive impairments. We have to ask, is the patient competent to make this choice or this decision about their care?
2. Does the patient truly understand the options? Patients should be presented with the options.
3. Is the patient being coerced? Families can have a big impact on patients. Is the patient being coerced or pushed toward a decision that maybe they don't want to make?
4. Who makes the decision if the patient can't?

Quality of Life

Quality of life can mean different things for different individuals.  Some view quality of life as, “Hey, I’m alive. This is great.”  While others may view their quality of life based on their physical abilities to participate in certain activities and if they can't, then their quality of life is decreased. Therefore, it becomes important to ask if the family’s perception of quality of life is the same as the patient’s. What one person feels is a breaking point for quality of life may be completely different from another person.  The patient may not want any further intervention and that may be the complete opposite of what the patient’s family wants.

Is there bias or prejudice in our decision-making? It may not be something we are consciously doing, but almost always you have some type of bias through your life experiences.  It is important that you step back and take your personal opinion and bias out of the decision-making.

Contextual Features

Patient care can be positively or negatively influenced by contextual features or constraints. Those may be financial; driven by payer type. They may be social, cultural or emotional. They could potentially be legal or even scientific. There may even be religious constraints with some specific belief sets.

Please refer to the SpeechPathology.com course, Our Aging Patients: Ethical Decision-making With the Aging Population, for more in-depth information on principles of bioethics and how they apply to ethical decision-making with the aging population.