Psychiatric Ethics in Late-Life Patients: Medicolegal and Forensic Aspects at the Interface of Mental Health

Part IEthical Aspects of Geriatric Psychiatry

© Springer Nature Switzerland AG 2019

Meera Balasubramaniam, Aarti Gupta and Rajesh R. Tampi (eds.)Psychiatric Ethics in Late-Life Patientshttps://doi.org/10.1007/978-3-030-15172-0_1

1. Aging: Balancing Autonomy and Beneficence

Reiko Emtman¹   and Jason Strauss²  

(1)

Boise VA Medical Center, Boise, ID, USA

(2)

Cambridge Health Alliance, Harvard Medical School, Everett, MA, USA

Reiko Emtman

Email: [email protected]

Jason Strauss (Corresponding author)

Email: [email protected]

Keywords

AutonomyBeneficenceEthicsAgingGeriatrics

Introduction

The silver tsunami is approaching. In 2014, there were 46 million people in the United States over the age of 65; 6 million of those were age 85 and older. By 2060, the number of individuals over age 65 will more than double to 98 million, and the number of individuals over age 85 will more than triple to 20 million [15]. In addition, the number of older adults with psychiatric and substance use disorder continues to increase at an appreciable rate. According to the Institute of Medicine (IOM), by 2030, expected growth in the older population will increase the number of older people with mental health and substance use conditions by 80% [12]. Moving forward, medical providers will be asked to confront an increasing number of challenges in navigating our professional desire to be as helpful as possible to our older patients when our recommendations do not align with their wishes.

As healthcare systems and providers strive to address the needs of an aging population, it is important to consider the potential impacts of aging on individual autonomy. Autonomy is freedom from external control or influence and is often considered synonymous with independence [2]. In the care of older adults, practitioners frequently encounter individuals who value and prioritize maintaining autonomy. Beneficence is defined as an action done to benefit others and has connotations of mercy, kindness, and promoting the good of others [2]. Benevolence is sometimes used to justify paternalism, or the concept that renders acceptable attempts to benefit another person, even when the other person does not prefer to receive benefit. Historically, physicians delivered medical care in a paternalistic way, where the expected dynamic in the healthcare relationship assigned authority and expertise to the physician, who provided education, recommendations, and advice to the patient [3].

Today’s healthcare system is moving away from a paternalistic model and toward self-management [3]. In this model, the focus of the clinical encounter is to teach problem-solving skills and promote patient self-efficacy as a way of managing chronic medical illnesses [3]. In working together to manage chronic disease collaboratively, the patient and the provider work toward patient-identified goals, which can have ego-syntonic effects even in the context of chronic illness.

The growing pains of this paradigm shift are reflected in the struggles of medical specialists adopting new terminology to refer to patients [19]. Psychiatry has struggled with whether to refer to individuals seeking psychiatric care as patients, as most of their medical colleagues do, or as clients, as is becoming more common among their mental health colleagues in psychology and social work [26]. A similar struggle has emerged for how to respectfully describe individuals who are farther along on the aging continuum: older adults, elderly, geriatric, seniors, aged, and the young-old versus old-old [11].

Ethical Frameworks in Medicine and Research : Integration of Autonomy and Beneficence

Several key frameworks are helpful in providing context for the discussion of autonomy and beneficence in older adults. In caring for older adults who commonly have multiple disease states in addition to physiologic changes with aging, the principles of autonomy and beneficence can come into conflict with one another [2, 5, 14, 20]. Clinical examples of conflicts between autonomy and beneficence will be discussed later in this chapter. Table 1.1 provides a comparison of four commonly used ethics frameworks for approaching issues that arise in the course of clinical practice.

Table 1.1

Ethical frameworks considering autonomy and benefi-cence

A detailed review of each of these ethical frameworks is outside the scope of this chapter. Table 1.1 compares four such frameworks. A brief introduction to each of the aforementioned models will be presented here. The moral principles outlined by Beauchamp and Childress [2] have been longstanding pillars in the realm of medical ethics [14]. Jonsen et al. designed a framework for medical professionals and professionals within the healthcare system to provide a practical approach to solving ethical issues that arise in the practice of medicine. The Charter on Medical professionalism, published in 2002, was designed to address ethical conflicts that arise in the context of healthcare systems in the new millennium and renew physicians’ commitments to the welfare of patients [5]. In 1974, the National Research Act became law, which created the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. The product of this commission, entitled The Belmont Report, outlined ethical principles pertaining to biomedical and behavioral research involving human subjects [20].

Next, we will examine the principle of autonomy as presented in each of these four frameworks. Figure 1.1 provides a concise summary of autonomy as presented in each framework.

Figure 1.1

Ethical frameworks of autonomy

In the practice of geriatrics , how far should clinicians go to respect autonomy of a patient? Under what circumstances is a paternalistic approach acceptable? Older adults will have varying degrees of decisional capacity, but it is important to recognize the distinction between autonomy and decisional capacity. Even individuals who lack the capability to make autonomous decisions can still make autonomous choices [13]. For example, an older adult who does not have the decisional capacity to refuse placement in a short-term rehabilitation facility can still make autonomous choices about meal preferences, choices about their daily routine, their level of participation in activities and whether to initiate social contact with others. Clinicians show respect for patient autonomy through their actions and clinical decision-making and should frame any treatment recommendations in terms of how each recommendation fits into helping the patient achieve their goals. Respecting autonomy requires clinicians to refrain from obstructing a patient’s right to make their own determinations or judgments [2]. Patient preferences incorporate the spirit of autonomy, without having the connotation that an individual must have decisional capacity for complete self-determination and instead shifts the focus to allowing choice wherever reasonable. A paternalistic approach that overrides patient autonomy is indicated when a person’s preferences and actions infringe on the rights and/or welfare of another individual. In geriatrics , autonomy may need to be overridden to protect the safety of family or professional caregivers, other residents in a facility and the health of the public.

The principle of beneficence is a universal goal of the healthcare system [2, 14]. Here, we will examine factors that can impede principles of beneficence in clinical practice and discuss the role of mental health providers in some common situations. These principles are also compared in Fig. 1.2. One example of this is when patients or their family members request medically inappropriate treatment. An example of this is the use of feeding tubes to treat dysphagia resulting from advanced dementia. Given the social, cultural, and sometimes religious significance of eating and sharing food, families can experience distress when their loved one is no longer able to eat, and request feeding tube placement. However, studies have shown that feeding tubes do not provide survival benefit when used in patients with advanced dementia and that use of feeding tubes is associated with higher rates of agitation, chemical, and physical restraint [1]. Another common clinical scenario when it can be difficult for providers to practice benevolence is in patients with severe personality disorders. Research shows that adults with personality disorders have a reduced life expectancy, which may be due to difficulties with interfacing effectively with healthcare systems [10, 22].

Figure 1.2

Ethical frameworks of beneficence

Physiologic Changes of Aging that Can Impact Autonomy

In this section, we will take an organ-systems approach to examine physiologic changes of aging that can contribute to decreased independence and recommend ways that psychiatric practice can promote autonomy. In order to provide optimal care for older adults, clinicians must integrate an understanding of the physiologic changes that occur with aging into their treatment plans and make appropriate referrals to interdisciplinary healthcare providers and subspecialists when indicated [16].

Physiologic changes that occur within the central nervous system with aging include a decrease in the number of neurotransmitters and their corresponding receptors, decreased dendritic branches at the neuronal level and formation of extracellular tangles and intracellular plaques [21]. Clinicians must remain vigilant about screening for psychiatric conditions that impact individuals of all ages: mood disorders, anxiety disorders, psychotic disorders , and substance use disorders and also pay close attention to domains of attention and cognition during an encounter with an older adult [6]. It is important to consider depression and pseudodementia on the differential diagnosis for individuals who appear to have cognitive deficits [8]. Individuals who have severe cognitive impairment tend to lose a degree of autonomy when another individual assumes a power of attorney or guardianship, but confidentiality and choice should be respected to the extent that is possible. Psychiatric providers should maintain a high degree of suspicion for medial etiologies of psychiatric illness and should have an understanding of psychiatric side effects of medical treatments as they may cause cognitive and functional impairments which can impede an individual’s autonomy [9].

Sensory impairment can have a significant impact on autonomy in older adults [7]. Clinicians should inquire about vision and hearing and refer to optometry, ophthalmology, and audiology as appropriate. An opportunity for clinicians to act in a beneficent manner in any setting is to maintain an environmental awareness and promptly address or report hazards such as wet floors, uneven surfaces to appropriate personnel to minimize the potential for accidents such as falls for individuals who, because of sensory limitations, are vulnerable to injury from environmental hazards.

Mobility issues can have a substantial impact on wellbeing and independence [18]. Physiologic changes of aging impact the musculoskeletal system and include sarcopenia, degenerative joint disease, osteopenia, and pathologic osteoporosis. These changes can increase the risk for falls and the likelihood of serious injury resulting from a fall. The benevolent psychiatric provider should be mindful about weighing benefits of psychiatric medications against potential for fall risk and ensuring appropriate referrals are placed for evaluation of home safety, strength, balance, and mobility issues as indicated. Neurophysiologic changes that occur with aging and often contribute to aforementioned issues with mobility include peripheral neuropathy, potential weakness from prior cerebrovascular accident(s), diminished reflexes, and slowed reaction time.

The physiology of aging in the cardiovascular system should also be taken into account when prescribing psychiatric medications [17]. Certain psychiatric medications can increase the risk of orthostatic hypotension and cardiac arrhythmias, which should be taken into consideration prior to initiating medication changes in older adults. The importance of collaborating with primary care providers and appropriate specialists cannot be overemphasized [25].

In the practice of geriatrics , clinicians must be able to apply the physiologic mechanisms of aging and combine the knowledge with clinical assessment of instrumental activities of daily living (ADLs), social supports, and quality of life to reach sound clinical decisions and offer medically appropriate interventions while withholding interventions that are unlikely to lead to achievement of a patient’s healthcare goals. Decisions regarding medical indications can be guided by use of frailty indexes which in turn, may improve beneficence of medical care offered and delivered, and offer a tool for prognostication [16].

Autonomy in the Clinical Encounter

Translating theoretical principles of autonomy into concrete action during a clinical encounter requires habitual incorporation of patient-centered communication styles. Table 1.2 examines ways in which the clinical encounter itself can foster or weaken autonomy.

Table 1.2

Examining autonomy in the clinical encounter

There are several tools available t o guide practitioners to facilitate a discussion about an individual’s wishes in hopes of preserving autonomy (Conversation Started Kit, [24]). In the United States, individuals can indicate their preferences regarding specific life-sustaining medical interventions such as cardiopulmonary resuscitation, artificial nutrition and hydration, and antibiotic use, among others. This document is known as an advance directive [4]. Individuals can also appoint a surrogate decision-maker who they have identified to make decisions about their medical care in the event that they are incapable of doing so themselves.

In addition to the legal methods that an individual can make their healthcare preferences known, clinicians should be aware of available clinical tools that can serve as a guide for providers to explore an individual patient’s values, and for patients to obtain information about their healthcare condition and its prognosis from their providers. Table 1.3 provides an example of tools that can be used to facilitate discussion with patients in the clinical setting (Conversation Starter Kit, [24]). The use of such tools can serve as a guide for surrogate decision-makers and providers, which can be a step toward preservation of autonomy.

Table 1.3

Clinical tools used to facilitate discussion of autonomy in making healthcare decisions

Beneficence in Clinical Practice

In addition to providing compassionate, evidence-based psychiatric care, psychiatrists providing care for older adults should be mindful of the team-based nature of healthcare for older adults [23]. Collaboration and communication with interdisciplinary members of the medical team are key, and psychiatrists can offer guidance on how to handle manifestations of personality disorders, characterological traits, and disinhibited behaviors, to name a few.

A familiarity with community and systemic supports designed to support older adults as they face common age-associated challenges available in the community is beneficial. Older adults can maintain autonomy and see benefits in their quality of life by utilizing programs and services such as adult day health, home caregivers, and senior transit options. Referral to caregiver support programs is another area that psychiatrists should be comfortable speaking to.

Beneficent behavior exists outside of the clinical encounter: alerting facility staff of environmental hazards that could lead to injury or falls and stopping to give directions to individuals who appear lost are common manifestations of beneficence on a healthcare campus.

Healthcare systems must adapt to needs of the older population and must take environmental concerns into account to care for an aging population: clinics for older adults must have relatively close proximity to a parking lot to be accessible to individuals with mobility limitations. Ways to deliver interdisciplinary healthcare to older adults in their home make these services accessible to a larger population.

Situations Where Autonomy and Beneficence May Conflict in Older Adults

Case #1

Mr. D is an 83-year-old male with depression, minor neurocognitive disorder, and hoarding disorder. He has been living at his skilled nursing facility for the past 2 years, after he was evicted from his senior housing in the community for repeated safety violations related to his hoarding disorder. Mr. D is generally well-liked by staff at the nursing facility, which he shares with two peers who are significantly more cognitively impaired than he is. Mr. D is noted to be pleasant and adherent with medications and daily care. He enjoys reading and spends time in the periphery of the milieu of his unit. However, he becomes passively suicidal, irritable, and occasionally combative with staff when his room is scheduled for its monthly cleaning. On one occasion, he was so distressed that he required inpatient psychiatric hospitalization. These behaviors have led to his being on escalating doses of antipsychotic medications.

Case #2

Ms. T is a 77-year-old female with chronic paranoid schizophrenia . She resides on a locked behavioral unit of a skilled nursing facility. Prior to transitioning to this facility, she had lived by herself. She never married, had few friends, and she had not kept in touch with family for many years. She worked from home and enjoyed participating in solitary activities. Ms. T has functionally declined and has become incontinent of bowel and urine. She has become increasingly reluctant to allow staff to provide any kind of care to her. She declines to bathe and will not partake in any attempts at grooming. Ultimately, she refuses to change her clothes even as they become increasingly soiled. Staff suspects that she has growing pressure ulcers at risk of being infected, but Ms. T refuses to allow her caregivers to check for them. She never becomes irritable or combative, but her resistance to care increases. Adjustments have been made to her antipsychotic regimen, but the behaviors have persisted. Peers on the unit (especially her two roommates) have noted the foul odor emanating from the room. In several cases, the smell has caused significant distress leading to worsening behavioral symptoms. Staff at the facility are increasingly reluctant to work with her and there is strong sentiment to psychiatrically hospitalize her.

Case #3

Mr. P is a 71-year-old male with post-traumatic stress disorder and major depressive disorder . He has chronic obstructive pulmonary disorder and must use oxygen through a nasal cannula. He lives alone in an apartment in a senior housing complex. He states that the only thing that brings him comfort is smoking, although there are strict building rules against doing this in his apartment. He was threatened with eviction following his second hospital admission in the past 3 months for pneumonia. He adamantly refuses to use a nicotine patch or gum and will not consider other interventions to curb his smoking. While he states that he understands the risks that his smoking presents to himself and others, he declines to change his behaviors. I’d rather be homeless than live here and not be able to smoke.

Case #4

Ms. S is a 62-year-old woman who is in a short-term rehabilitation facility. She was recently hospitalized for a right arm cellulitis which was felt to be related to her longstanding intravenous heroin use. She currently has a peripherally inserted central catheter (PICC) so that she can receive antibiotics for the next 4 weeks