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.

Developing a list of treatment options for a patient is a central component of good decision making. Two assumptions help in developing options for a patient. First, although society’s financial concerns are an issue, the choices made with a particular patient are ordinarily assumed to have negligible effects upon society as a whole, neither greatly changing costs nor depleting other resources. For example, choosing to dialyze an elderly, disabled patient is usually assumed to have no major effect upon the availability of dialysis to others. Although society’s financial concerns usually do not limit the options for a particular patient at a particular time, financial concerns may exclude certain options for everyone. Second, all available options, including forgoing specific treatment, should be considered. Thus, a patient with an embolic stroke will have at least the options of (1) having only supportive care for comfort and function, (2) having further diagnostic studies to better assess the risks of recurrence, and (3) receiving anticoagulation therapy. Proceeding directly to full diagnosis and treatment without considering the merits of forgoing specific diagnosis and treatment often is not the best choice.
Decision making may be inappropriately simplified by either-or choices, in which one option is held to be unacceptable. An example is the notion that a provider must always give “ordinary” treatments but that “extraordinary” or “heroic” efforts need not be made. One might also be permitted to “allow a patient to die” but not to “kill a patient.”
Relying on such either-or choices misleadingly reduces a complex situation to simple moral alternatives. This approach is a poor substitute for one in which choices are made to advance the patient’s best interests—as the patient defines them. Advancing the patient’s interests may involve stopping a treatment; deciding not to use the usual array of interventions, such as antibiotics or feeding tubes; or giving medications that may lead to an earlier death while relieving symptoms.
Appeal to the common distinction between ordinary and extraordinary treatments is made in cases in which some question exists about the obligation to treat. This use of the distinction raises two problems. First, rapidly changing technologies and views about which practices are indicated constantly alter a descriptive definition of ordinary care. Second, and more serious from an ethical point of view, noting that a practice is common is irrelevant to deciding whether it is morally right.
The terms ordinary and extraordinary are used in a variety of ways— to indicate whether treatment is usual, complex, artificial, expensive, or available. Care that is extraordinary in the sense that it is rare might be morally required for a limited time in an unusual case. For example, a patient appropriately may be given ventilator support in dire circumstances precipitated by an unexpected complication of experimental therapy, even though thelikelihood of survival is so poor that a ventilator might not be used otherwise.
Ordinary and extraordinary are useful terms to express one’s conclusions about the ethical evaluation of a situation, but they do not define the appropriateness of treatment. The terms are helpful only when used to indicate whether the burdens imposed by a treatment are disproportionate to its benefits. Thus, when a patient prefers death to prolonged suffering, even treatment with antibiotics may be considered extraordinary.
Many physicians express reservations about withdrawing treatment when, all other things being equal, they would not have had doubts about withholding treatment. There are often powerful psychological inhibitions against stopping treatment, but there is usually no moral difference between not starting treatment and stopping it once it has started. Attempting a treatment may help determine whether it provides a benefit. Admitting that the treatment is not achieving the desired benefit is more painful (and stopping it often entails more documentation than not starting it would have), but such problems can usually be mitigated by having planned end points of therapeutic trials. Such planning is as necessary for the use of nasogastric feeding tubes as it is for more complicated interventions, such as dialysis or repeated blood transfusions. In each case, the best decision cannot be known until after treatment is initiated. Simply put, a physician need not continue a course of treatment that is not working merely because that treatment was started.
Certain prudent steps should be taken whenever care involves an action that may shorten the patient’s life, for example, administering high-dose narcotics for pain or respiratory distress, forgoing antibiotics or feeding tubes, or agreeing to withhold a life-sustaining transfusion or radiation treatment. (1) The physician must be sure that the plan is correctly assessed; for instance, the prognosis should be diligently evaluated. (2) Respected colleagues (including nurses, social workers, and clergy) should be asked to evaluate the situation. If they disagree with
the plan, usually it should be reassessed and implementation delayed. (3) The physician must try to determine whether the patient agrees with the plan (or would have agreed were the patient competent). (4) The decision-making process should be carefully documented. (5) The physician might arrange for a formal review by an ethics or patient care committee or for a court review. This last step is emotionally and financially costly and usually unnecessary if the first four steps are followed.

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.

Just as patients may refuse treatment, they also may request treatment, including treatment to prolong life. Physicians have a strong obligation to respect a competent patient’s request, an advance directive, or a surrogate’s decision to prolong life. However, certain relevant limitations exist. Physicians are not obliged to provide physiologically futile treatments—that is, treatments that cannot produce the desired physiologic change. Before withholding or withdrawing treatment, physicians should be as sure as possible that it is futile, and they should have a full, open discussion with the patient or the surrogate about the nature and extent of the futility of the treatment. If a requested treatment entails a loss of function, mutilation, or pain disproportionate to benefit, the physician is not obliged to provide it. Also, a physician who has a conscientious objection to a requested treatment is not obliged to provide it. The physician should explain all treatment options and the physician’s position regarding them. If the patient wishes, the physician should arrange an orderly transfer to another physician of the patient’s choice.

Just as patients must be informed of their rights to make decisions about treatments and to give advance directives, patients should also have the opportunity to state whether they want to have CPR performed in the event of a cardiopulmonary arrest. In almost all jurisdictions, patients do not have a legal right to euthanasia, but responding to a request for euthanasia poses difficult ethical issues for the physician.

Strictly speaking, do-not-resuscitate (DNR) orders mean only that CPR should not be performed for a cardiopulmonary arrest. Other treatment—such as antibiotics, transfusions, dialysis, and ventilator support—may still be given. More specific orders are required to indicate whether the person should be hospitalized or whether a patient should be treated in an intensive care unit.
To assist physicians in managing the care of patients for whom CPR may not be appropriate, the American Medical Association Council on Ethical and Judicial Affairs in 1991 issued the following guidelines.
1.    Efforts should be made to resuscitate patients who suffer cardiac
or respiratory arrest except when CPR would be futile or not in accor
dance with the desires or best interests of the patient.
2.    Physicians should discuss the possibility of cardiopulmonary ar
rest with appropriate patients and encourage them to state whether
v wiiiil CPR. The discussions should include a description of CPR \ctltiirs and, when possible, should occur in an outpatient setting N< iin;il treatment preferences are discussed or as early as possi-IHMI lu’M'ilali/ation, when the patient is likely to be mentally vl» tli<u iiHsiuns before an emergency arises help ensure the pa-<?». iihtittiii HI the decision-making process. Subsequent periodic discussions can determine if the patient has changed his mind because his circumstances or the treatment alternatives have changed.
3.    If a patient is incapable of making a decision about CPR, the surro
gate may make it, based on the patient’s previously expressed prefer
ences or, if such preferences are unknown, in accordance with the pa
tient’s best interests.
4.    The physician has an ethical obligation to honor the resuscitation
preferences expressed by the patient or the surrogate. Physicians
should not allow their personal value judgments about quality of life to
affect the implementation of a patient’s or surrogate’s preferences re
garding the use of CPR. However, if in the physician’s judgment CPR
would be futile, the physician may enter a DNR order into the patient’s
record. If time permits, the physician must inform the patient or the
surrogate of the content of the DNR order and the basis for its imple
mentation. The physician also should be prepared to discuss appropri
ate alternatives, such as obtaining a second opinion or arranging for a
transfer of care to another physician.
5.    Resuscitative efforts should be considered futile only if they can
not be expected to restore cardiac or respiratory function or to achieve
the patient’s expressed goals.
6.    The DNR orders, as well as the basis for their implementation,
should be entered by the attending physician in the patient’s medical
record.
7.    The DNR orders preclude only resuscitation efforts in the event of
cardiopulmonary arrest, not other therapeutic interventions that are
appropriate for the patient.
8.    Hospital medical staffs should periodically review their experi
ence with DNR orders, revise their DNR policies as appropriate, and
inform physicians about their role in the decision-making process for
DNR orders.

Requests for euthanasia by competent patients suffering severely and irremediably from an incurable disease are understandable; however, legally they cannot be honored. Physicians are obliged to provide treatment and care that results in a peaceful, dignified, and humane death with minimal physical suffering. Statutory legalization of euthanasia by physicians could have an adverse impact on society. Thoughtful decisions to forgo life-sustaining treatment together with sustained, comprehensive symptom relief and emotional and spiritual support could provide an effective alternative to euthanasia for most dying patients.
However, some physicians and advocacy groups contend that physicians should be allowed to actively assist those who cannot commit suicide because of extreme infirmity and who prefer death to continued suffering. Physicians caring for the elderly have an obligation to be engaged in this policy debate and to seek to ensure safeguards for vulnerable patients and stewardship of the public trust.

The social context of geriatric care influences the risk of disease, the experience of illness, and the physician’s ability to deliver timely and appropriate care. The social status of the elderly, the changing demographics of health and illness, and evolving social values exert complex pressures on the patchwork of policies, programs, and services that constitute the continuum of care available to the elderly. Thus, the successful practice of geriatric medicine requires an understanding of the broader context in which illness occurs and care is provided.

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.