ISD II – Subspecialties

Ethical/Legal Issues in Care of Geriatric Patients

June 6, 2003

CASE HISTORY (Part 1):

Mr. Spencer, an 85 year-old male, had been living with his son Eugene on the southern shore.

In September Mr. Spencer slipped and fell. This resulted in a fracture of his right hip. He subsequently had surgery. His course in hospital was complicated because of his longstanding moderate aortic stenosis. He had been noted to have a normal ejection fraction but had left ventricular hypertrophy. He had a past history of hypertension and also peripheral vascular disease with a history of claudication. He also had longstanding ischemic heart disease and his post-operative course was complicated by rapid atrial fibrillation and congestive heart failure. He required cardioversion on two occasions and was treated with amiodarone.

Approximately two weeks after his fall he was transferred to the Geriatric Treatment and Assessment Unit. Dr. Day, the attending physician in the unit, reviewed his history with him. It was noted that prior to admission to hospital Mr. Spencer had been able to perform all activities of daily living. There was some question of mild cognitive changes. The issue of cardiac resuscitation was discussed. Mr. Spencer requested that in the event he went into cardiac arrest he should not be resuscitated.

Mr. Spencer underwent a course of extensive occupational as well as physiotherapy. However he was found to be poorly motivated. He complained of pain in his left knee, which was attributed to osteoarthritis. There was some evidence of inflammation and steroid injections were given. He also complained of visual impairment and insisted on a referral to an eye doctor. He was subsequently diagnosed as having cataracts.

Mr. Spencer experienced recurrent epigastric burning as well as chest pain. Dr. Day thought this might be due to gastroesophageal reflux. In December because of these severe recurrent pains Dr. Day referred him for an upper GI endoscopy. Mr. Spencer's son Eugene accompanied him for this procedure which was performed at another hospital. Dr. Fry, the endoscopist, detected a large ulceration in Mr. Spencer's stomach. He informed Eugene that Mr. Spencer probably had cancer.

Questions for Part 1

1. What if any ethical issues arise with regard to the care and treatment of Mr. Spencer to this point?

2 Is it appropriate to provide active intervention for Mr. Spencer, or should his care plan be directed toward palliative measures?

CASE HISTORY (Part 2):

When Mr. Spencer was returned to the ward Eugene asked to speak to the attending physician Dr. Day. He requested that the diagnosis not be discussed with his father, as he was concerned he would be very distressed by this news. Dr. Day stated that he felt it was his ethical obligation to discuss the diagnosis with the patient, and it would be impossible to come up with a treatment plan without this discussion. Eugene argued that he knew his father much better than Dr. Day, and was prepared to discuss treatment options on his father's behalf. In any case he was sure that his father's severe heart disease meant he would not withstand a surgical procedure anyway.

The biopsy results of the endoscopy were pending. Dr. Day informed Eugene that when the biopsy was available he would ask Mr. Spencer what information he desired.

At this point Eugene insisted that his father should be transferred to another physician. Dr. Day agreed to contact other physicians to see if any would be willing to have Mr. Spencer transferred to their care.

Questions for Part 2

1. What if any ethical issues are evident at this point?

2. What information do you need in order to assess the ethical dimensions of this part of the case?

3. Given the information available to you, has Dr. Day acted appropriately? Why or why not?

CASE HISTORY (Part 3):

At this point Dr. Smith, another physician in the rehab hospital, said he would consider taking Mr. Spencer as his patient. He subsequently came to the ward to see Mr. Spencer at which time he agreed to take the patient in transfer.

Two days later while on a ward round, Dr. Day stopped to speak briefly with his former patient Mr. Spencer. He asked if the family had explained why he had been transferred and he said they hadn’t. Dr. Day asked him if he had met the new physician Dr. Smith. He said he had. He stated that Dr. Smith “had asked a bunch of foolish questions regarding counting, and remembering things."

Dr. Day then reviewed Mr. Spencer's chart. He saw that Dr. Smith had written a progress note in which he stated that in addition to his previous documented problems Mr. Spencer now had “dementia”. The note stated that Mr. Spencer had scored 18 out of 30 on a mini-mental status exam.

Dr. Day then wrote a progress note to the effect that the patient did not have dementia and could remember details of his mental status examination.

In consultation with Mr. Spencer's family, Dr. Smith embarked on a course of palliative care. Mr. Spencer was prescribed morphine and a variety of medications were either decreased or discontinued including cardiac medications. The patient subsequently suffered extensive diarrhoea and dehydration and died.

Questions for Part 3:

1. Based on the available information, was Mr. Spencer's care handled appropriately?

2. Did Dr. Day act appropriately? Did he fulfill his moral obligations to Mr. Spencer?

3. Has Dr. Smith acted in a legal and ethical manner in his care and treatment of Mr. Spencer?

Please be prepared to discuss the following issues in the seminar as they relate to the case:

1. Autonomy and principles of decision making including the obligation for disclosure of information to the patient.

2. Capacity and competence and demonstrate their assessment.

3. Informed consent and substitute consent.

4. Power of attorney and guardianship.

5. Legal and ethical issues involving advance health care directives.

6. Legislation which has a bearing on the above questions including the Neglected Adult Act, The Advance Health Care Directive Legislation, An Act Respecting Enduring Powers of Attorney, the Guardian Act and the Mental Health Act.

REFERENCES: (http://www.cma.ca/cmaj/series/bioethic.htm).

1. Bioethics for Clinicians: 1. Consent. CMAJ, 1996, 155: 177-180.

2. Bioethics for Clinicians: 3. Capacity. CMAJ, 1996, 155: 657-661.

3. Bioethics for Clinicians: 5. Subsitite Decision Making. CMAJ, 1996, 155: 1435-1437.

4. Bioethics for Clinicians: 6. Advance Care Planning. CMAJ, 1996, 155: 1689-1692.

5. Bioethics for Clinicians: 7. Truth Telling. CMAJ, 1997, 156: 225-228.

6. Bioethics for Clinicians: 15 Quality end-of-life care. CMAJ, 1998, 159: 159-162.