Geriatrics L3 - Ethics, Financing, and the Organization and Levels of Healthcare

what is medical ethics?

what has become a required presence in hospitals, nursing homes, and other healthcare organizations?

the discipline that studies morality in healthcare

ethics committees

in geriatrics, what influences medical decisions?

- limited life expectancy

- cognitive impairment

- impaired decision-making capacity

- insufficient social/economic resources

what does informed consent require?

what does disclosure allow?

what is significant about voluntariness?

disclosure, comprehension, voluntary and competent decision-making

to weigh the risks/benefits of proposed intervention but also any alternatives including doing nothing

confirm that a patient's decision is not coerced

what is competence?

what is decision-making capacity?

a legal term that refers to soundness of mind to make most routine decisions

a clinical term that determines the capability to rend a specific decision about a patient's care

what should a provider determine as part of the process of obtaining informed consent?

patient's capacity

t/f: the inability to provide consent for one intervention does not indicate incapacity for other decision

true

1 multiple choice option

1st step of determining capacity?

2nd step of determining capacity?

3rd step of determining capacity?

4th step of determining capacity?

ensure no communication barriers are present

evaluate for reversible causes of incapacity

consider patient's values and culture

assess the four elements of capacity standards

what is the decision-making capacity set of standards?

- understanding

- appreciation

- reasoning (with information)

- expressing (a choice)

if there is a question whether a patient meets all four standards, what can be used?

what formal assessment is used?

formal assessment

Assessment of Capacity for Everyday Decisions (ACED): a standardized questionnaire that must be interpreted in the context of a patient's scenario

if a patient clearly lacks capacity for informed consent, what should be used?

what is a healthcare proxy?

what does it mean for a substitute surrogate to be "reasonably available"?

a substitute: healthcare surrogate or power of attorney (POA) as part of an advanced directive

a surrogate or agent who can make medical decisions should a patient lose decision-making capcity

able to be contacted and act within a timely manner

what is part of an advanced directive?

- healthcare proxy

- living will

- physician order for life-sustaining treatment

what is a living will?

what risk is involved in a living will?

a written statement of preferences for care when decision-making capacity is lost

the stipulations listed might not apply to the specific circumstances a patient finds themselves in

what is POLST/MOST?

what does POLST/MOST address?

who completes POLST/MOSt?

a set of orders based on a patient's current condition and anticipated trajectory and stipulates which interventions should be provided or withheld

the preferences of patients who have serious illnesses, such as resuscitation, antibiotics, fluids, and nutrition

providers

what is medical aid in dying (MAID) or physician-assisted dying (PAD)?

what is voluntary active euthanasia (VAE)?

a practice in which the physician provides a qualified patient, as their explicit request, with a prescription for a lethal medication that they can take on their own

a practice whereby the physician administers a lethal medication at the patient's request, usually by IV injection

t/f: MAID/PAD is illegal in the US, but VAE is legal in several states, including north carolina

false: MAID/PAD is legal in most states, but VAE is not legal anywhere in the US

where should you refer a patient who is requesting MAID/PAD?

palliative care/hospice

what is the "double effect"?

the concern that narcotic dosages used to treat pain and discomfort will also hasten death

what is voluntary stopping eating and drinking (VSED)?

patients who choose to stop eating and drinking to hasten death

who does Medicare cover?

- available to everyone ≥ 65 years who has paid Medicare payroll taxes for at least 10 years in their lifetime

- anyone younger than 65 years if they have ESRD or ALS, or receive social security disability insurance

what is covered by Medicare Part A?

- most people who do not pay a premium for Part A

- hospitalizations

- post-acute rehab, not long-term nursing homes or assisted living care facilities

- home healthcare

- hospice

- durable medical equipment (DME)

what is covered by Medicare Part B?

what are some examples of outpatient services?

visits to clinicians and services that occur on an outpatient basis

ambulatory surgery, same-day procedures, labs/diagnostic tests

what is Medicare Part C?

- an alternative to traditional fee-for-service (Parts A/B)

- Medicare pays an organization a risk-adjusted sum per member per month that covers all Medicare-reimbursed services for enrolled members

- organized by specific geographic area

what is covered by Medicare Part D?

what is the coverage gap, or "donut hole"?

what was removed as part of Medicare Part D in 2025?

prescriptions

provides coverage up to a certain limit, until the drug cost reaches a "catastrophic level"

the "donut hole" and copays/deductibles for recommended vaccines

what are some risks associated with hospitals?

what is the chance of an older adult developing an ADL disability during a hospitalization?

loss of independence, falls, delirium/cognitive loss, healthcare-associated infections

30%

what are acute care for the elderly (ACE) units?

how are these units unique?

specific areas in hospitals designed to meet needs of older patients

incorporate changes in both the physical environment and overall care approach (home-like setting)

what are some risk factors of delirium?

- cognitive impairment

- depression, alcohol abuse, hearing/vision loss

- use of anticholinergics

- dehydration or malnutrition

what are some ways to prevent delirium?

- at least 4-6 hours of uninterrupted sleep every night

- keep the light on during the daytime hours

- personal items and hearing aids/glasses in the room

- avoid anticholinergics/benzos when possible

- manage pain and constipation appropriately

what are some risk factors for falls?

- poor coordination, tremor, weakness, or sensory changes

- orthostatic hypotension

- joint pain/effusions, antalgic gait

- Abnormal Timed Up and Go Test

what should be assessed for on admission?

what can be given to patients with a low risk for VTE?

what should be given to patients with a moderate/high risk for VTE?

risk factors for VTE

mechanical prophylaxis: pneumatic compression, compression stockings

low molecular weight heparin (LMWH)

why is skin care important in older adults?

what can be used for bed-bound or immobile patients?

older adults are more susceptible to skin injury

pressure-reducing supports: cushions and repositioning Q2 hours

why is there an increased risk of respiratory illness in older adults?

how can respiratory illness be prevented/

due to reduced mobility, exposure to other infected patients, prolonged supine positioning, pain

incentive spirometry, deep breathing exercises, encouraging mobility, continue inhalers, sit upright for meals

how can infection be prevented in older adults?

- strict adherence to hand washing and isolation protocols

- judicious use of IV/urinary catheters and other invasive monitoring devices

how can nutrition be maintained in older adults?

- consider if assistance with meals is needed

- avoid diet restrictions unless necessary

- offer nutritional supplements

- consider consistency of solids/liquids in patients with dysphagia

- consults with speech therapy or nutrition

how can mobility and function be maintained in older adults?

- limit restricted activity orders and hospital equipment

- early referral to OT/PT

what is the target blood sugar range in non-critically ill patients?

what is the target blood sugar range in critically ill patients?

how can glycemic control be maintained in older adults?

pre-prandial < 140 mg/dL and random < 180 mg/dL

140-180 mg/dL

avoid hypoglycemia and hyperglycemia

what are the types of long-term care (LTC)?

- nursing homes

- residential care/assisted living communities

- continuing care retirement communities

- adult daycare

- program for all-inclusive care for the elderly (PACE)

- community services and supports

what are common clinical challenges in LTCs?

- assessing change in cognition

- addressing neuropsychiatric symptoms of dementia

- pressure ulcers

- falls

- infections

- UTIs, norovirus, C. diff, flu, pneumonia

who qualifies for LTCs?

- homebound patients with a skilled need, through Medicare

- medically complex or conditions refractory to office-based care

- frail patients who are unable to access office-based visits due to functional impairments

what are the types of home care?

- home healthcare through Medicare

- medical home visits/house calls

- hospital at home

how is a patient eligible for short-term rehab (STR)?

what is the goal of STR?

what is the Medicare criteria for STRs?

if skilled needs are required following hospitalization

improve function or medical condition and return home

at least 3 consecutive hospital inpatient days within 30 days of STR admission and physician certification that patient requires daily skilled care

what types of services are provided in STRs?

- administration of IV medications

- wound care

- PT/OT

- speech therapy