Issues
Ethical issues
in the care
of the elderly
Dr. Jeff Blackmer
A
s our population ages, clinicians will care for an
increasing number of elderly patients. Just as
these patients may present unique and challeng-
ing medical dilemmas, so may they also present ethical
ones. The case studies that follow are intended to pro-
vide a brief overview of 3 types of situations that may
raise ethical concerns: capacity and consent, living wills
and substitute decision-making, and do-not-resuscitate
orders. Although these are not the only ethical concerns
that may arise during care of the elderly (and are not
unique to this population), they represent the most
common scenarios that clinicians may encounter in the
everyday course of their practice.
Capacity and consent
A 65-year-old woman presents to her family doctor’s
office with complaints of memory loss and occasional
confusion. This history is confirmed by her daughter,
who has accompanied her. The physician suggests per-
forming several tests, including some genetic testing to
determine whether the patient may be at risk for various
types of dementia. The patient appears to have some
trouble understanding why the physician is requesting
these tests and becomes agitated and upset. How should
the physician proceed?
The principle of respect for patient autonomy refers
to the duty to respect people and their right to self-
determination. The concept of informed consent requires
that patients be fully informed of all treatment and test-
ing options for their condition or situation, that they be
able to understand these options and that they have
time to consider them fully. Informed consent should be
obtained when ordering tests whose results are likely to
have a significant impact on future care of the patient.
In this case, with the patient’s complaint of memory
loss and confusion, there may be some concern about
her ability to fully appreciate the information being pre-
sented to her. Some patients are capable of making some
decisions but not others, depending on the circumstances.
In this case, the physician should try to determine
whether the patient understands the information that is
being presented to her and the possible consequences of
the test results. Given the patient’s current state of agita-
tion, she may also benefit from written information.
The physician should also involve the patient’s
daughter in the discussion. She may be able to explain
the information to her mother in a way that it will be
better understood. The fact that genetic testing, which
may have an impact on the daughter, is being discussed
means that it is also preferable to have her involved in
assisting her mother with the decision-making process.
In the end, competent patients are able to make their
own decisions independent of family members, but
enlisting the assistance of family members in situations
like this will often be helpful.
Living wills and substitute decision-
making
A 72-year-old man with chronic obstructive pulmonary
disease (COPD) is seen in the emergency room following
an exacerbation. He is stabilized and nearly ready to be
discharged. The resident on duty asks him and his wife if
they have considered whether he wants to be mechani-
cally ventilated, if this were to be required at some point
in the future. He and his wife exchange confused
glances; no one has ever discussed this issue with them.
What should the resident do?
The ability to make autonomous decisions need not
end with loss of capacity. Providing verbal or (even
better) written advance directives (written advance
Elder Care 23
 Issues
directives are often referred to as a living will) allows
patients to maintain control over what will be done to
their body even in situations where they are not able to
express their wishes directly. These directives have
proved to be most effective when they can be applied to
specific medical conditions, such as COPD exacerba-
tions in the example above. The patient can make deci-
sions regarding a specific medical condition and specific
treatment options. For example, after a discussion with
his physicians of the various pros and cons of ventilation
and other treatment options, this patient may decide
that he does not wish to be placed on a mechanical ven-
tilator if he should become unable to breathe for himself.
By expressing this wish in advance, he will remove the
guesswork for medical professionals involved in his
future care and also ensure that his wishes are respected
and his autonomy is maintained.
In the process of completing an advance directive,
most patients will also appoint a substitute decision-maker.
Generally this is someone very close to the patient who
knows him or her well. Sometimes this will be based on
a specific discussion or set of instructions (I do not want
to be kept alive on a ventilator), sometimes it will be
based on the patient’s deeply held beliefs (I do not feel
that life is worth preserving at any costs; I never want to
be a burden on my loved ones). Physicians should also
turn to the substitute decision-maker for help in inter-
preting a patient’s living will, particularly if there is any
ambiguity. Physicians should be familiar with the rele-
vant legislation governing advance directives and substi-
tute decision-makers in their particular jurisdiction.
The resident in this case should take the time to sit
down with the patient and his wife and inform them of
their options. They should be given all the relevant infor-
mation they might need to arrive at a decision. They should
be told how to complete a living will and be encouraged
to do so, and to make their other family members and
their family physician aware of their decisions.
Do-not-resuscitate orders
An 87-year-old woman is admitted to the oncology
ward with abdominal pain and distention. Investigations
reveal that her previously diagnosed intestinal cancer
has worsened and has metastasized extensively. Her
prognosis is very poor and her physicians are only able
to offer pain control and palliation. In spite of this, her
immediate family members insist that everything possible
be done to resuscitate her if she goes into cardiac or res-
piratory arrest. The health care team is very concerned
about this. As the attending physician on the unit, you
have been asked to address the situation. What will you do?
Do-not-resuscitate (DNR) orders may become a
point of contention among patients, their families and
24 Issues and options for Canadian physicians
health care workers. Patients wish to make autonomous
decisions about what will be done to their bodies if they
suffer a cardiac or pulmonary arrest. Physicians want to
be beneficent and help their patients, but they are also
mindful that certain interventions are more likely to cause
harm than benefit and that some simply will not work
in a particular situation (i.e., they will be medically futile).
When a patient and his or her physician agree that
the patient should not be resuscitated, a DNR order is
placed in the patient’s chart or file and the relevant per-
sons are notified. The patient should be given all the infor-
mation necessary to arrive at this decision and should
know that it can be revisited in the future. It should also
be made clear to all concerned that do not resuscitate does
not mean do not treat and that the patient should other-
wise be offered all relevant treatment options.
The more contentious issue often arises when a
patient or the family members demand that a patient be
resuscitated and the physician or health care team disagrees
with this decision. Reasons for such a demand may be var-
ied and should be explored. Some patients feel that life
in itself is ultimately valued no matter what its subjective
quality may be and that any and all measures should be
taken to maintain life. They may also have a mispercep-
tion of the chance of success of resuscitation in certain
circumstances and of the potential damage it may do.
It is always preferable to arrive at a mutually agree-
able joint decision with the patient. When the physician
truly feels that resuscitation would be of no benefit and
in fact may instead be harmful to the patient, most
experts agree that it need not be offered as a treatment
option, as it would be considered medically futile.
Physicians who choose this route should do so with cau-
tion and should make every effort to involve the patient
and the family in the decision-making process to the
greatest extent possible.
In this case, the attending physician should explore
the reasons behind the family’s decision. The family
should be provided with all the necessary information,
including the fact that there is essentially no chance that
this patient will leave hospital following an arrest, even
in the extremely unlikely event that she is successfully
resuscitated. The physician should explain that every-
thing possible will be done to keep the patient comfort-
able and her care will not be abandoned. Palliative care
options should be discussed. The family should be given
time to consider the information. As a last resort, the
physician may consider unilaterally writing a DNR
order in spite of the opposition of the family. It may be
helpful to obtain a second opinion in this situation.
Dr. Jeff Blackmer is Executive Director, Office of Ethics for
the Canadian Medical Association.