Obtaining informed consent is the formal component of shared decision making by the physician and patient. Unfortunately, the documents developed by institutions to formally record the process of obtaining consent are often substituted for the process itself. Informed consent embodies certain conditions that must be satisfied; these include adequate information, freedom from coercion, and sufficient decision-making capacity. The patient’s lifestyle, the likely functional outcome of each choice, and psychosocial factors will affect what the patient needs to know.

The physician should ensure that the patient can comprehend information well enough to make important life choices. Facts about the patient’s medical condition and available interventions, including their risks and benefits, should be explained to and understood by the patient. Not all minor or rare risks or benefits need to be articulated, but those that could be expected to affect a particular patient’s choice need to be explained. Limiting or forgoing treatment and the consequential risks and benefits ordinarily should be discussed.
Certain attributes of informed consent are especially important with the older patient. The physician must ensure that the patient is not coerced—for instance, by the family or physician imposing goals and values—and that the patient does not acquiesce because of a desire to please others or a perceived loss of self-determination and independence (as may occur with institutionalized or profoundly dependent home-care patients). The process of obtaining informed consent from an older person may require more time because of sensory deficits or slowed cognition

In some cases, disagreement arises over the choice of treatment. If the physician believes the patient is making a poor choice because of a lack of knowledge or information, the physician must inform the patient more fully. A competent patient can always abandon medical care, but a physician cannot abandon a patient. A competent patient’s choice will almost invariably be upheld in court.
Nevertheless, a physician is not required to honor a patient’s treatment choice if the physician strongly disagrees with it, even if the patient is competent. If such issues cannot be resolved, the physician can withdraw from the case after examining the risks and benefits of each treatment option, the patient’s right to self-determination, and the physician’s own commitment to current practice standards and professional integrity. If the physician decides to withdraw, the patient should be notified, perhaps by certified mail. Care should be terminated only upon referral to another physician or after giving the patient ample opportunity to find another physician.
When a patient lacks capacity to make medical decisions or has been declared incompetent by a court, a surrogate decision maker is usually needed. A surrogate is the person who should best know the wishes of the patient and thus is able to speak for the patient. The surrogate may be the next of kin, someone granted durable power of attorney for health care decisions by the patient, or someone appointed by the court. Ch. 108 discusses surrogate decision makers

Obtaining informed consent is the formal component of shared decision making by the physician and patient. Unfortunately, the documents developed by institutions to formally record the process of obtaining consent are often substituted for the process itself. Informed consent embodies certain conditions that must be satisfied; these include adequate information, freedom from coercion, and sufficient decision-making capacity. The patient’s lifestyle, the likely functional outcome of each choice, and psychosocial factors will affect what the patient needs to know.

The physician should ensure that the patient can comprehend information well enough to make important life choices. Facts about the patient’s medical condition and available interventions, including their risks and benefits, should be explained to and understood by the patient. Not all minor or rare risks or benefits need to be articulated, but those that could be expected to affect a particular patient’s choice need to be explained. Limiting or forgoing treatment and the consequential risks and benefits ordinarily should be discussed.
Certain attributes of informed consent are especially important with the older patient. The physician must ensure that the patient is not coerced—for instance, by the family or physician imposing goals and values—and that the patient does not acquiesce because of a desire to please others or a perceived loss of self-determination and independence (as may occur with institutionalized or profoundly dependent home-care patients). The process of obtaining informed consent from an older person may require more time because of sensory deficits or slowed cognition.

If a competent patient rejects treatment that the physician believes is in the patient’s interest, especially if the treatment would prolong life, the physician should explore the patient’s reasons and correct any misunderstandings. However, a physician should not impose treatment if the patient refuses it—even if the treatment could prolong life. Instead, the physician should explore alternatives that might be acceptable to the patient; as discussed earlier, sometimes this involves transferring the patient to the care of a physician or institution that will respect the patient’s wishes. In all cases, including those in which a patient refuses a specific treatment, the physician and the institution have an obligation to continue offering supportive care and treatment for pain and suffering.
Physicians and other health care providers should also respect advance directives to refuse treatment given by patients who have become incompetent as well as decisions to refuse treatment made by the patient’s appointed representatives (see ADVANCE DIRECTIVES in Ch. 108). If a patient becomes incompetent and no advance directive exists, there is a strong tradition that the next of kin (often an adult child or spouse who is likely to know and share the patient’s values) makes decisions for the patient. However, sometimes the next of kin is emotionally distant or hostile, and another person, such as a friend, may be a better surrogate. When someone other than the next of kin is the designated surrogate, the reasons for the choice should be documented.
Often, the surrogate for an elderly person is a group of family members who may disagree with one another. If the controversy threatens to obstruct what seems to be the best course of action, the physician may call upon clergy, nurses, social workers, or the hospital ethics committee to help resolve the conflict. If this approach is unsuccessful, an outside review and court-appointed guardianship may be necessary.

USE OF HEALTH CARE SERVICES
Older persons are more likely to use health care services than younger persons. While the elderly made up only 12% of the US population in 1990, they accounted for 34% of all hospital stays and 45% of all hospital days. For persons over age 65, the average length of stay was 8.7 days; for persons under age 65, it was 5.3 days. In 1990, older persons averaged nine contacts with physicians, while those under age 65 averaged only five contacts. Per capita spending on health care for those age 65 and older was $5360, compared with $1286 for those under age 65. Persons over age 65 use 34% of all prescription medications, with older Americans taking an average of 4.5 medications at any one time.
Older persons also use institutional services, such as nursing homes, more than younger persons. Evolving social and demographic dynamics have reduced the number of family members available to care for impaired elders. Older persons, particularly women, are likely to be widowed, and when they become very old, their children may be elderly themselves. The increasingly transient and mobile nature of American society and the increased divorce rate have contributed to geographic separation of families and weaker family ties.
The number of single-parent households, most headed by women, continues to grow. This phenomenon as well as new economic and social realities that foster a dependence on two-income households have produced a steady growth of women in the work force—women who in the past would have functioned as caregivers. Today, the demands of a job may diminish a woman’s ability to provide the informal support needed by elderly relatives. These factors together with the increased prevalence of disease suggest that the demand for both noninstitutional support systems and institutional services by an expanding population of dependent elderly will continue to grow.

Although social support includes help from neighbors and friends, family members usually provide most of the physical, emotional, social, and economic support. Family caregivers play a key role in delaying, if not preventing, institutionalization of the chronically ill older person. In fact, about 80% of home health care is provided as informal support by family members (as opposed to purchased services). This care is provided to elderly persons living with adult children or in their own homes.
The amount and type of care depend on economic resources, family structure, quality of relationships, and competing demands on family time and energy. Family caregiving can range from minimal assistance (eg, periodically checking in) to elaborate full-time care. On average, caregivers spend about 4 h a day on caregiving tasks. Women are more likely than men to be both receivers and givers of such care.
Spouses are major providers of care for the frail elderly. While adult children frequently care for mildly or moderately impaired elders, a spouse (usually a wife) is more likely to care for a severely disabled elderly person. Spouse caregivers experience considerable stress and suffer associated health problems. As a group, caregiving couples are disproportionately poor, and the caregiver is usually in poor health.
Recent demographic trends of delayed procreation and increased longevity have created a “sandwich generation” of caregivers who find themselves responsible for care of both their children and their parents. Many of these caregivers who have jobs experience significant conflict between the demands of their job and those of elder care. Although society tends to view families as having special rights and responsibilities in caring for one another, the limits of filial and spousal obligations vary among families and individuals.
Family members’ willingness and ability to provide care may be enhanced by services that support family caregivers (technical assistance in learning new skills, counseling services, family mental health services, or personal supports) and services that supplement family caregiving (personal care, home health care, adult day care, meals programs, and social services).
Lack of support or social isolation is associated with an increased risk of mortality. Social supports, however, appear to buffer the elderly from the negative effects of life transitions, such as the departure of children, retirement, and widowhood.

Special housing for the elderly varies widely. Life-care communities (or continuing care retirement communities) are the most comprehensive, providing apartments for independent living and a range of services, including skilled nursing care. Most life-care communities have a single campus; some provide services at several sites. With congregate care, older persons live in individual apartments or rooms and receive selected services. Congregate care differs from a life-care community in that the residents do not own their units, and there is no commitment to provide care over time as residents’ needs change. Foster, domiciliary, and personal-care homes generally offer room, board, and some supervision. The availability of these housing options, particularly those providing supervision, is woefully inadequate in most communities.
Hospice care provides services intended to improve the quality of life for terminally ill patients so they can live the remainder of their lives as comfortably and peacefully as possible. Many aspects of hospice care are being adopted by care providers in the general health system and have been suggested for patients with certain illnesses (eg, Alzheimer’s disease), even when death is not imminent.
Respite care refers to services that allow family members time away from caregiving responsibilities. Services range from an in-home visit of a few hours by a volunteer or paid worker to institutional stays of several weeks. Respite care continues to evolve as a valuable resource for those coping with the stresses of providing care to an aged spouse, sibling, or parent.
Community mental health centers provide ambulatory psychiatric care and other services to residents in catchment areas. Generally, the number of elderly persons who actually receive these services is much smaller than the number of persons who need them, but several centers have special outreach programs, nursing home consultation, and other services for geriatric patients.
Adult day care serves persons who need supervision or medical services during the day but who can spend evenings with family members or in other supportive environments. Two types of adult day care exist: the adult day hospital and the multipurpose, social, day-care center. Some adult day hospitals focus specifically on psychiatric patients. Despite significant fragmentation in funding and regulation, adult day-care centers have increased from 800 in 1987 to nearly 3000 in 1992.
Senior centers provide opportunities for social contact and recreational activities. They also serve as convenient sites for health screening, nutrition and education programs, and outreach activities. Most offer meals on weekdays, and some have extensive health and social service programs, including adult day care.
Nutrition programs provide two types of services—congregate meals and home-delivered meals. Congregate meals not only contribute to nutritional health but also provide opportunities for social contact, educational programs, and outreach efforts. Meals for the homebound or meals-on-wheels provides an important service to elders who are unable to shop, prepare meals, or follow special dietary regimens.
Home health care includes a wide range of services, such as skilled
nursing care; occupational, physical, and speech therapy; medical so
cial services; physician care; nutritional and dietary services and
meals; homemaker services; home health aide services; respiratory
and IV therapy; and medical supplies, including drugs and medical ap
pliances.    . .
Monitoring services such as telephone networks and friendly visitors,
keep health care systems in touch with chronically impaired or frail
persons living at home. These services can be a secondary function of
other services.    /

Health care is provided to veterans without charge for service-connected disabilities and, on a complicated priority basis, for other conditions. The Veterans Administration operates 172 hospitals, 16 domiciliary facilities, and more than 100 nursing homes; it also contracts for care in community hospitals and nursing homes. The Veterans Administration has launched several innovative geriatric programs, including geriatric assessment units (GAUs), Geriatric Research, Education and Clinical Centers (GRECCs), and hospital-based home health care programs.