Ethical challenges in end-of-life therapies in the elderly

With the increasing numbers of elderly in the population of all western countries and the increasing life expectancy at birth, many seniors spend the last period of their life with various afflictions that may require the need for long-term institutional care. During the last period of life, many seniors and their families face decisions that challenge ethical principles and may cause conflict among family members as well as healthcare professionals. The commonly used ethical principles of autonomy, beneficence, nonmaleficence and justice, although forming a useful foundation for the evaluation of decision-making dilemmas, alone cannot resolve many clinically challenging situations. Healthcare professionals must clearly understand the clinical state of the patient for whom a difficult decision is being contemplated. Levels of function, clinical symptoms, the expected trajectory of change and possible treatment options have to be balanced against the person's values and wishes, either self-expressed directly or through an advance directive, or communicated by surrogate decision makers. At times, physicians face difficult treatment dilemmas when patients or families request treatments that are not legally sanctioned, such as when physician-assisted suicide is requested by a suffering patient. At other times conflicts occur when patients or surrogates wish to continue with therapies that are no longer considered necessary or suitable by the physician. At the societal level, sometimes an expensive drug that is deemed necessary by the physicians is not covered by a government-sponsored or private health plan. The issue of distributive justice must be considered in a situation such as when long-term facilities or acute hospitals treating frail, cognitively impaired elders consider withholding or withdrawing various treatments because of poor clinical outcomes coupled with excessive costs. The often controversial issue of nutrition and hydration in the end-of-life period frequently causes treatment conflicts and dilemmas among surrogates and staff, as does the highly charged issue of cardiopulmonary resuscitation in this frail and very vulnerable population. The real challenge for healthcare providers in the field of geriatric long-term care is to balance compassionate and appropriate care with respect for the choices and wishes of patients and their families. This should be accomplished while at the same time safeguarding the professional standards and ethical integrity of healthcare providers responsible for this care.