Advertisement

Ethical Issues of Emergency Medical Care for Older Patients

  • Helen Askitopoulou
  • Katrin Singler
  • Thomas Frühwald
  • Monique Weissenberger-Leduc
Chapter

Abstract

Ethics are central to the clinical practice of quality emergency medicine. Emergency physicians must be able to recognise the ethical issues in the care of older patients who present to the emergency department and to respond to them in a manner that will provide the greatest benefit for each patient. The human rights of this vulnerable and diverse ageing population should be preserved and protected by unified and coordinated efforts. The decisions about the emergency treatment of these patients should be based on the moral framework of the four ethical principles of autonomy, non-maleficence, beneficence and justice. These principles serve as a useful framework for the main ethical issues involved in the emergency care of older people such as decision-making capacity, advance directives, fairness of treatment and resource allocation, end-of-life decisions, do not attempt resuscitation (DNAR) orders, older abuse and dementia. The same ethical principles should be considered when ensuring the ability of older patients to fulfil the requirements of ethical research in the emergency department.

References

  1. 1.
    Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ (2009) Emergency department crowding, part 1- concept, causes, and moral consequences. Ann Emerg Med 53:605–611.  https://doi.org/10.1016/j.annemergmed.2008.09.019 CrossRefPubMedGoogle Scholar
  2. 2.
    American College of Emergency Physicians (2008) Code of ethics for emergency physicians. Ann Emerg Med 52:581–590Google Scholar
  3. 3.
    Pauls M, Leblanc C, Campbell S (2002) Ethics in the trenches: preparing for ethical challenges in the emergency department. CJEM 4:45–48CrossRefGoogle Scholar
  4. 4.
    Sanders AB (1995) Unique aspects of ethics in emergency medicine. In: Iserson KV, Sanders AB, Mathieu D (eds) Ethics in emergency medicine, 2nd edn. Galen Press Ltd, Tucso, pp 7–10Google Scholar
  5. 5.
    Baker C (2015) Accident and emergency statistics. House of commons. briefing paper No. 6964Google Scholar
  6. 6.
    Samaras N, Chevalley T, Samaras D, Gold G (2010) Older patients in the emergency department: a review. Ann Emerg Med 56:261–269.  https://doi.org/10.1016/j.annemergmed.2010.04.015 CrossRefGoogle Scholar
  7. 7.
    Adams J, Wolfson AB (1990) Ethical issues in geriatric emergency medicine. Emerg Med Clin North Am 8(2):183–192PubMedGoogle Scholar
  8. 8.
    Beauchamp TL, Childress JF (2009) Principles of biomedical ethics. Oxford University Press, New York, p. (a) 1, (b) 16–25, (c) 99–105, (d) 149–155, (e) 167–168, (f) 197, (g) 240–252, (h) 248–249Google Scholar
  9. 9.
    van Potter R (1970) Bioethics, science of survival. Persp Biol Med 14:127–153CrossRefGoogle Scholar
  10. 10.
    Schneiderman LJ (2011) Defining medical futility and improving medical care. J Bioeth Inq 8:123–131CrossRefGoogle Scholar
  11. 11.
    Aacharya RP, Gastmans C, Denier Y (2011) Emergency department triage: an ethical analysis. BMC Emerg Med 11:16.  https://doi.org/10.1186/1471-227X-11-16 CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kaldjian LC, Weir RF, Duffy TP (2004) A clinician’s approach to clinical ethical reasoning. J Gen Intern Med. 20(3):306–311CrossRefGoogle Scholar
  13. 13.
    Bossaert LL, Perkins GD, Askitopoulou H, Raffay VI, Greif R, Haywood KL et al (2016) Reply to letter: family presence during cardiopulmonary resuscitation: evidence-based guidelines? Resuscitation 105:e7–e8.  https://doi.org/10.1016/j.resuscitation.2016.05.003 CrossRefPubMedGoogle Scholar
  14. 14.
    Das AK, Mulley GP (2005) The value of an ethics history? J R Soc Med 98(6):262–266CrossRefGoogle Scholar
  15. 15.
    Larkin GL, Marco CA, Abbott JT (2001) Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department. Acad Emerg Med 8(3):282–284CrossRefGoogle Scholar
  16. 16.
    Pellegrino ED (2000) Decisions to withdraw life-sustaining treatment: a moral algorithm. JAMA 283(8):1065–1067CrossRefGoogle Scholar
  17. 17.
    Royal College of Emergency Medicine (2015) End of life care for adults in the emergency department. Best practice guideline. Royal College of Emergency Medicine, LondonGoogle Scholar
  18. 18.
    Mueller PS, Hook CC, Fleming KC (2004) Ethical issues in geriatrics: a guide for clinicians. Mayo Clin Proc 79:554–562CrossRefGoogle Scholar
  19. 19.
    Singler K, Thiem U, Christ M, Zenk P, Biber R, Sieber CC et al (2014) Aspects and assessment of delirium in old age. First data from a German interdisciplinary emergency department. Z Gerontol Geriatr 47:680–685.  https://doi.org/10.1007/s00391-014-0615-z CrossRefPubMedGoogle Scholar
  20. 20.
    Davis MA, Hoffman JR, Hsu J (1999) Impact of patient acuity on preference for information and autonomy in decision making. Acad Emerg Med 6(8):781–785CrossRefGoogle Scholar
  21. 21.
    Sokol DK (2015) Update on the UK law on consent. BMJ 350:h1481CrossRefGoogle Scholar
  22. 22.
    Ha JF, Anat DS, Longnecker N (2010) Doctor-patient communication: a review. Ochsner J 10(1):38–43PubMedPubMedCentralGoogle Scholar
  23. 23.
    Dong X (2014) Elder abuse: research, practice, and health policy. The 2012 GSA Maxwell Pollack award lecture. Gerontologist 54(2):153–162CrossRefGoogle Scholar
  24. 24.
    Iserson KV (2004) Ethical considerations in emergency care. Israeli J Emerg Med 4(2):10–17Google Scholar
  25. 25.
    Lloyd G, Skarratts D, Robinson N, Reid C (2000) Communication skills training for emergency department senior house officers—a qualitative study. J Accid Emerg Med 17:246–250CrossRefGoogle Scholar
  26. 26.
    Johnston C, Liddle J (2007) The Mental Capacity Act 2005: a new framework for healthcare decision making. J Med Ethics 33:94–97CrossRefGoogle Scholar
  27. 27.
    Andorno R, Biller-Andorno N, Brauer S (2009) Advance health care directives: towards a coordinated European policy? Eur J Health Law 16:207–227CrossRefGoogle Scholar
  28. 28.
    Aw D, Hayhoe B, Smajdor A, Bowker LK, Conroy SP, Myint PK (2012) Advance care planning and the older patient. Q J Med 105:225–230.  https://doi.org/10.1093/qjmed/hcr209 CrossRefGoogle Scholar
  29. 29.
    Shaw D (2012) A direct advance on advance directives. Bioethics 26(5):267–274CrossRefGoogle Scholar
  30. 30.
    Marco CA, Bessman ES, Kelen GD (2009) Ethical issues of cardiopulmonary resuscitation: comparison of emergency physician practices from 1995 to 2007. Acad Emerg Med 16:270–273CrossRefGoogle Scholar
  31. 31.
    Puchalski C, Zhong Z, Jacobs MM, Fox E, Lynn J, Harrold J et al (2000) Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. J Am Geriatr Soc 48(Suppl 5):84–90CrossRefGoogle Scholar
  32. 32.
    Shalowitz DI, Garrett-Meyer E, Wendler D (2006) The accuracy of surrogate decision makers. A systematic review. Arch Internal Med 166:493–497CrossRefGoogle Scholar
  33. 33.
    Mentzelopoulos S, Bossaert L, Raffay V, Askitopoulou H, Perkins GD, Greif R et al (2016) A survey of key opinion leaders on ethical resuscitation practices in 31 European countries. Resuscitation 100:11–17.  https://doi.org/10.1016/j.resuscitation.2015.12.010 CrossRefPubMedGoogle Scholar
  34. 34.
    Jones WHS (2004) Hippocrates. Epidemics I. The Loeb Classical Library, I. Harvard University Press, Cambridge, XI.9–15Google Scholar
  35. 35.
    Jones WHS (1998) Hippocrates. The Art. Vol. II. The Loeb Classical Library. Harvard University Press, Cambridge. (a) Chapter III.8–10, (b) Chapter XIV.2–3Google Scholar
  36. 36.
    Mason JK, Laurie GT (2011) Mason and McCall Smith’s law and medical ethics, 8th edn. Oxford University Press, Oxford, p 476Google Scholar
  37. 37.
    World Medical Association (2009) Medical ethics manual, 2nd edn. The World Medical Association, Inc, France. http://www.wma.net/en/30publications/30ethicsmanual/pdf/ethics_manual_en.pdf. Accessed 23 Mar 2015
  38. 38.
    Council of Europe (2014) Committee on bioethics (DH-BIO). Guide on the decision-making process regarding medical treatment in end-of-life situations. http://www.coe.int/t/dg3/healthbioethic/conferences_and_symposia/Guide%20FDV%20E.pdf. Accessed 13 Feb 2015
  39. 39.
    Blinderman CD, Krakauer EL, Solomon MZ (2012) Time to revise the approach to determining cardiopulmonary resuscitation status. JAMA 307(9):917–918.  https://doi.org/10.1001/jama.2012.236 CrossRefPubMedGoogle Scholar
  40. 40.
    Kidd AC, Honney K, Myint PK, Holland R, Bowker LK (2014) Does medical futility matter in ‘do not attempt CPR’ decision-making? Int J Clin Pract 68(10):1190–1192.  https://doi.org/10.1111/ijcp.12476 CrossRefPubMedGoogle Scholar
  41. 41.
    British Medical Association (2007) Withholding or withdrawing life-prolonging medical treatment. Guidance for decision making, 3rd edn. Blackwell Publishing, LondonGoogle Scholar
  42. 42.
    General Medical Council (2010) Treatment and care towards the end of life: good practice in decision making. General Medical Council, ManchesterGoogle Scholar
  43. 43.
    Manalo MFC (2013) End-of-life decisions about withholding or withdrawing therapy: medical, ethical, and religio-cultural considerations. Palliat Care 7:1–5PubMedPubMedCentralGoogle Scholar
  44. 44.
    Vincent J-L (2005) Withdrawing may be preferable to withholding. Critical Care 9:226–229CrossRefGoogle Scholar
  45. 45.
    Conroy S, Fade P, Fraser A, Schiff R, Guideline Development Group (2009) Advance care planning: concise evidence-based guidelines. Clin Med 9:76–79CrossRefGoogle Scholar
  46. 46.
    Bossaert LL, Perkins GD, Askitopoulou H, Raffay VI, Greif R, Haywood KL et al (2015) European resuscitation council guidelines for resuscitation 2015: section 11. The ethics of resuscitation and end-of-life decisions. Resuscitation 95:302–311.  https://doi.org/10.1016/j.resuscitation.2015.07.033 CrossRefPubMedGoogle Scholar
  47. 47.
    Marco CA, Larkin GL, Moskop JC, Derse AR (2000) Determination of “futility” in emergency medicine. Ann Emerg Med 35(6):604–612CrossRefGoogle Scholar
  48. 48.
    Jones WHS (2004) Hippocrates. The Oath. The Loeb Classical Library, vol I. Harvard University Press, CambridgeGoogle Scholar
  49. 49.
    Denny DL, Guido GW (2012) Under treatment of pain in older adults: an application of beneficence. Nurs Ethics 19(6):800–809CrossRefGoogle Scholar
  50. 50.
    Larkin GL, Moskop J, Sanders A, Derse A (1994) The emergency physician and patient confidentiality: a review. Ann Emerg Med 24:1161–1167CrossRefGoogle Scholar
  51. 51.
    Moskop JC, Marco CA, Larkin GL, Geiderman JM, Derse AR (2005) From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine—part II: challenges in the emergency department. Ann Emerg Med 45:60–67CrossRefGoogle Scholar
  52. 52.
    Schmidt TA, Beckman A, Bradley R, DiGioia N, Girod J, Hollingsworth S, et al (2005) Guide to teaching ethics in emergency medicine residency programs. SAEM Ethics Committee. http://www.saem.org/docs/default-source/education/ethics-guide.pdf?sfvrsn=0. Accessed 5 Feb 2016
  53. 53.
    Truog RD, Brett AS, Frader J (1992) The problem with futility. N Engl J Med 326(23):1560–1564CrossRefGoogle Scholar
  54. 54.
    Rackham H (1934) Aristotle. Nicomachean ethics. The Loeb Classical Library, vol IV. Harvard University Press, Cambridge, pp 8–11Google Scholar
  55. 55.
    Harris J, Regmi S (2012) Ageism and equality. J Med Ethics 38(5):263–266CrossRefGoogle Scholar
  56. 56.
    Detering KM, Hancock AD, Reade MC, Silvester W (2010) The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ 340:c1345.  https://doi.org/10.1136/bmj.c1345 CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Huerta-Alardín AL, Guerra-Cantú M, Varon J (2007) Cardiopulmonary resuscitation in the elderly: a clinical and ethical perspective. J Geriatr Cardiol 4:117–119Google Scholar
  58. 58.
    Cooper S, Janghorbani M, Cooper G (2006) A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation 68(2):231–237CrossRefGoogle Scholar
  59. 59.
    Hilberman M, Kutner J, Parsons D, Murphy DJ (1997) Marginally effective medical care: ethical analysis of issues in cardiopulmonary resuscitation (CPR). J Med Ethics 23:361–367CrossRefGoogle Scholar
  60. 60.
    Holm S, Jørgensen EO (2001) Ethical issues in cardiopulmonary resuscitation. Resuscitation 50:135–139CrossRefGoogle Scholar
  61. 61.
    Deasy C, Bray JE, Smith K, Harriss LR, Bernard SA, Cameron P et al (2011) Out-of-hospital cardiac arrests in the older age groups in Melbourne, Australia. Resuscitation 82:398–403.  https://doi.org/10.1016/j.resuscitation.2010.12.016 CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Swor R, Jackson RE, Tintinalli JE et al (2000) Does advanced age matter in outcomes after out-of-hospital cardiac arrest in community-dwelling adults? Acad Emerg Med 7:762–768CrossRefGoogle Scholar
  63. 63.
    Lannon R, O’Keeffe ST (2010) Cardiopulmonary resuscitation in older people—a review. Rev Clin Gerontol 20:20–29CrossRefGoogle Scholar
  64. 64.
    Truhlár A, Deakin CD, Soar J, Khalifa GE, Alfonzo A, Bierens JJ et al (2015) European resuscitation council guidelines for resuscitation 2015: section 4. Cardiac arrest in special circumstances. Resuscitation 95:148–201.  https://doi.org/10.1016/j.resuscitation.2015.07.017 CrossRefPubMedGoogle Scholar
  65. 65.
    Elshove-Bolk J, Guttormsen A, Austlid I (2007) In-hospital resuscitation of the elderly: characteristics and outcome. Resuscitation 10:1–5Google Scholar
  66. 66.
    Larkin GL, Copes WS, Nathanson BH, Kaye W (2010) Pre-resuscitation factors associated with mortality in 49,130 cases of in-hospital cardiac arrest: a report from the National Registry for Cardiopulmonary Resuscitation. Resuscitation 81(3):302–311.  https://doi.org/10.1016/j.resuscitation.2009.11.021 CrossRefPubMedGoogle Scholar
  67. 67.
    Boyd R (2000) Witnessed resuscitation by relatives. Resuscitation 43:171–176CrossRefGoogle Scholar
  68. 68.
    Engel KG, Barnosky AR, Berry-Bovia M, Desmond JS, Ubel PA (2007) Provider experience and attitudes toward family presence during resuscitation procedures. J Palliative Med 10(5):1007–1009CrossRefGoogle Scholar
  69. 69.
    Compton S, Magdy A, Goldstein M, Sandhu J, Dunne R, Swor R (2006) Emergency medical service providers’ experience with family presence during cardiopulmonary resuscitation. Resuscitation 70:223–228CrossRefGoogle Scholar
  70. 70.
    Critchell CD, Marik PE (2007) Should family members be present during cardiopulmonary resuscitation? A review of the literature. Am J Hosp Palliat Care 24(4):311–317CrossRefGoogle Scholar
  71. 71.
    Mitchel MH, Lynch MB (1997) Should relatives be allowed in the resuscitation room? J Accid Emerg Med 14:366–369CrossRefGoogle Scholar
  72. 72.
    British Medical Association, Resuscitation Council (UK) and Royal College of Nursing (2014) Decisions relating to cardiopulmonary resuscitation. Guidance from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. 3rd edn. https://www.resus.org.uk/dnacpr/decisions-relating-to-cpr/. Accessed 23 Mar 2015
  73. 73.
    Morrison LJ, Gerald K, Diekema DS, Sayre MR, Silvers SM, Idris AH et al (2010) Part 3: ethics: American Heart Association 2010 guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122(Suppl 3):665–675.  https://doi.org/10.1161/CIRCULATIONAHA.110.970905 CrossRefGoogle Scholar
  74. 74.
    Snyder L (2012) American college of physicians ethics manual, 6th edn. American College of Physicians, PhiladelphiaGoogle Scholar
  75. 75.
    Mockford C, Fritz Z, George R, Court R, Grove A, Clarke B et al (2015) Do not attempt cardiopulmonary resuscitation (DNACPR) orders: a systematic review of the barriers and facilitators of decision-making and implementation. Resuscitation 88:99–113.  https://doi.org/10.1016/j.resuscitation.2014.11.016 CrossRefPubMedGoogle Scholar
  76. 76.
    European Court of Human Rights (2016) European convention on human rights. http://www.echr.coe.int/Documents/Convention_ENG.pdf. Accessed 28 Mar 2016
  77. 77.
    Fritz Z, Cork N, Dodd A, Malyon A (2014) DNACPR decisions: challenging and changing practice in the wake of the Tracey judgment. Clin Med 14:571–576.  https://doi.org/10.7861/clinmedicine.14-6-571 CrossRefGoogle Scholar
  78. 78.
    Cherniack EP (2002) Increasing use of DNR orders in the elderly worldwide: whose choice is it? J Med Ethics 28:303–307CrossRefGoogle Scholar
  79. 79.
    Bishop J, Brothers K, Perry J, Ahmad A (2010) Reviving the conversation around CPR/DNR. Am J Bioeth 10(1):61–67.  https://doi.org/10.1080/15265160903469328 CrossRefPubMedGoogle Scholar
  80. 80.
    Lachs MS, Pillemer K (2004) Elder abuse. Lancet 364:1263–1272CrossRefGoogle Scholar
  81. 81.
    World Health Organisation (2002) The Toronto declaration on the global prevention of elder abuse, Geneva. http://www.who.int/ageing/projects/elder_abuse/alc_toronto_declaration_en.pdf. Accessed 3 Feb 2016
  82. 82.
    Cooper C, Selwood A, Livingston G (2008) The prevalence of elder abuse and neglect: a systematic review. Age and Ageing 37:151–160CrossRefGoogle Scholar
  83. 83.
    World Health Organisation (2002) Active ageing: a policy framework. A contribution of the World Health Organization to the Second United Nations World Assembly on Ageing, Madrid, Spain. http://apps.who.int/iris/bitstream/10665/67215/1/WHO_NMH_NPH_02.8.pdf. Accessed 3 Feb 2016
  84. 84.
    McAlpine C (2008) Elder abuse and neglect. Age Ageing 37(2):132–133CrossRefGoogle Scholar
  85. 85.
    Phelan A (2012) Elder abuse in the emergency department. Intern Emerg Nurs 20:214–220CrossRefGoogle Scholar
  86. 86.
    Hope T, Askham J, Baker M, et al (2009) For the working group of the Nuffield Council on Bioethics. Dementia: ethical issues. Nuffield Council on Bioethics, LondonGoogle Scholar
  87. 87.
    Council of Europe (2009) The convention on human rights and biomedicine (Oviedo, 4.IV.1997). Treaty No 164. http://conventions.coe.int/Treaty/en/Treaties/Html/164.htm. Accessed 23 Mar 2015
  88. 88.
    World Medical Association (2013) Declaration of Helsinki ethical principles for medical research involving human subjects. 64th WMA general assembly, Fortaleza, Brazil. http://www.wma.net/en/30publications/10policies/b3/. Accessed 23 Mar 2015
  89. 89.
    Nee PA, Griffiths RD (2002) Ethical considerations in accident and emergency research. Emerg Med J 19:423–427CrossRefGoogle Scholar
  90. 90.
    Annas GJ, Grodin MA (1992) The Nazi doctors and the Nuremberg code: human rights in human experimentation. Oxford University Press, OxfordGoogle Scholar
  91. 91.
    Halila R (2007) Assessing the ethics of medical research in emergency settings: how do international regulations work in practice? Sci Eng Ethics 13(3):305–313CrossRefGoogle Scholar
  92. 92.
    Kompanje EJO, Maas AIR, Menon DK, Kesecioglu J (2014) Medical research in emergency research in the European Union member states: tensions between theory and practice. Intens Care Med 40(4):496–503.  https://doi.org/10.1007/s00134-014-3243-6 CrossRefGoogle Scholar
  93. 93.
    Quest T, Marco CA (2003) Ethics seminars: vulnerable populations in emergency medicine research. Acad Emerg Med 10:1294–1298CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2018

Authors and Affiliations

  • Helen Askitopoulou
    • 1
    • 2
  • Katrin Singler
    • 3
    • 4
  • Thomas Frühwald
    • 5
  • Monique Weissenberger-Leduc
    • 6
  1. 1.Faculty of MedicineUniversity of CreteHeraklion, CreteGreece
  2. 2.European Society for Emergency Medicine (EUSEM) Ethics CommitteeRethymnoGreece
  3. 3.Internal Medicine, Geriatrics, Institute for Biomedicine of AgingFriedrich-Alexander University Erlangen-NürnbergErlangenGermany
  4. 4.Klinikum NürnbergParacelsus Private Medical UniversityNürnbergGermany
  5. 5.Austrian Society of Geriatrics and GerontologyWienAustria
  6. 6.Forum Palliative Praxis GeriatrieViennaAustria

Personalised recommendations