Originally published March 2012
As the Canadian population ages, physicians will treat a greater number of older adults. While physicians' fundamental responsibilities do not vary due to a patient's age, there are medico-legal considerations to keep in mind when caring for an aging patient. Physicians may have to adapt their approach for this demographic.
Communicating with older adults
Physician-patient communication takes on added significance when dealing with an elderly patient population.
The factors contributing to an effective physician-patient exchange such as politeness, parity,1 and patience become more important2. There are also a number of other communication-related issues that are particularly relevant to aging adults3.
When scheduling appointments, physicians should plan to spend extra time with older patients. Time is needed to establish rapport, listen attentively, share information, examine the patient, provide education and counselling, and provide opportunities for patient questions or feedback. Physicians should be mindful that some older patients may not ask questions or challenge their doctor because of generational differences, reluctance to complain, or fear of hearing the diagnosis. Doctors should take the time needed to check understanding, discuss options, and invite questions.
Older adults may have an increased incidence of sensory impairments such as hearing or vision loss, so physicians may sometimes need to speak more slowly and clearly. Facing the patient directly, maintaining eye contact, writing out important terms, and using printed materials with easy-to-read typefaces or pictures may also be helpful. As with all patients, it is beneficial to use plain language and frequently check patient understanding. Physicians should also remember that aging patients, with or without sensory impairments, want to be treated as equals and not paternalistically.
Confronting topics such as memory loss, cognitive impairment, and loss of independence (such as giving up a driver's licence) can create discomfort for physicians and patients alike. Approaches to help physicians discuss awkward topics include generalizing the information, telling anecdotes without breaching confidentiality, and providing relevant literature to the patient and family members.
In all cases, discussions with patients should be documented in the medical record. This is important for continuity of care and provides the best evidence of the physician-patient discussion.
Continuity of care
Continuity of care generally refers to the process by which the patient and healthcare professionals collaborate in the management of the patient's care. The ultimate goal of continuity of care is quality and safety of care. The following continuity of care issues are particularly relevant to caring for aging patients.
Many aging patients have multiple health conditions that require care by more than one physician, and sometimes by other healthcare professionals. Physicians should work collaboratively with other health professionals, communicate fully and promptly in writing or by telephone with other care providers, and engage patients in their medical care. In working with other healthcare professionals, physicians should also be aware of scopes of practice, roles and responsibilities, and applicable policies and procedures. Timely follow-up on test results and effective patient handovers between physicians are also beneficial to the patient's safety.
In Canada, the courts have elaborated on the duty of physicians to appropriately inform patients in the post-operative or post-discharge period. A physician should conduct a full discussion with the patient about post-treatment risks or complications, informing the patient of clinical signs and symptoms that would indicate the need to seek further medical attention. Standardized discharge instructions may assist physicians in this regard. It is particularly important that physicians make efforts to ascertain whether aging patients appear to understand the instructions. One approach is to ask patients to summarize their discharge instructions and to ask if they have any questions. Printed information in a large font and clear illustrations may also help older adults.
It may be appropriate to involve family members in the care of elderly patients. This does not negate a physician's obligation to privacy and confidentiality. Any discussion regarding the health of an elderly patient should only be done with express consent of the mentally capable patient. If consent is granted by the patient, it should be documented in the patient's medical record.
Managing medications for aging patients can be challenging. Issues include multiple medications which may lead to drug interactions, age-related changes that may affect a drug's effect, as well as negative side effects.
There are a number of medico-legal issues associated with medications and elderly patients. These commonly include inadequate patient evaluation prior to prescribing, incorrect dispensing or administering of a medication by other healthcare professionals, prescribing or administering an incorrect dosage of a medication, delaying or failing to prescribe or administer an indicated medication, and prescribing a medication with significant contraindications. Physicians should take extra care when prescribing and managing medications for older adults.
Medication reconciliation is another important aspect of medication management for aging patients. Accurate and complete medication information must be communicated at all transitions of care. Physicians are a part of the multidisciplinary team and should be involved in medication reconciliation at admission, during in-hospital transfer, and when elderly patients are discharged.
A particular concern is the unintentional discontinuance of medication for seniors being discharged from hospital. Discontinuing a medication can have serious consequences such as hospital readmissions, visits to the emergency department, and even death.4
Physicians should review the list of patient medications when receiving the patient from home, the community, or from within a hospital, and also when transferring or discharging the patient. Changes in medications made during a hospital visit should be reviewed carefully with aging patients prior to discharge or transition. The use of established medication management systems (e.g. preprinted forms or integrated computer systems) should be considered to facilitate continuity of care.
Physicians have reporting obligations that may be specific to aging patients. For example, physicians should be aware of their reporting obligations when health conditions may make it dangerous for an individual to drive.
Elder abuse and neglect encompass a range of behaviours including emotional, financial, physical, and sexual abuse, and neglect by other individuals5. Physicians may be among the first to see the effects of elder abuse. Doctors should be attentive to the signs of abuse and neglect. When physicians have reasonable grounds to suspect that a nursing home resident has suffered or may suffer harm due to unlawful conduct, incompetent care, treatment, or neglect, they may be required by provincial or territorial legislation to report this information.
Self-neglect among older adults is also a reality. Signs of self-neglect may include little or no personal care, inability to keep up social contacts, refusing medication, a disoriented or incoherent manner, unsafe living conditions, and alcohol or drug dependence6. Physicians must address self-neglect among older adults, and public health and interdisciplinary approaches may also be required.
The exact requirements for mandatory reporting and those related to elder abuse vary by province and territory, so physicians should be aware of the regulations in their jurisdiction and may consider their regulatory authority (College) as a source of information. Members may also contact the CMPA for guidance and to discuss specific cases in confidence.
Legally, an adult patient is capable of consenting to investigation and treatment unless there is a reason to believe otherwise — regardless of age.
A patient who is able to understand the nature and anticipated effects of a proposed investigation or treatment, including the consequences of refusing, is generally considered mentally capable of giving consent. Physicians should remember that incapacity can be temporary, and so it may be necessary to reassess capacity at appropriate intervals. Physicians should strive to resolve issues concerning capacity to consent through discussions with the aging patient and family. To help avoid medico-legal issues associated with capacity and consent, physicians should keep relevant, detailed notes in the medical record.
With few exceptions, physicians must obtain valid consent before treatment is administered to a patient.
To help meet the legal standards applicable to the law of consent, physicians should discuss the nature and anticipated effect of any proposed treatment with the patient, including risks and alternatives. The patient should always be given the time to ask questions. Some aging patients may also have health issues or circumstances that may require a physician to disclose rare, but possible side effects or drawbacks to a treatment. Physicians should be careful about accepting waivers from aging patients and should seek to engage them in decisions related to their health and care. The CMPA has numerous resources on consent, including articles such as "Is this patient capable of consenting?", an eLearning activity, "Informed Consent", and the booklet, Consent: A guide for Canadian physicians.
Substitute consent and decision
A person suffering from mental incapacity may still retain sufficient mental ability to give valid consent to medical treatment. This depends on whether the patient is able to adequately appreciate the nature of the proposed treatment, its anticipated effect, and the alternatives. This is no different for an aging patient.
Provincial and territorial legislation provide a means to obtain substitute consent when a patient is incapable of giving valid consent. Substitute decision-makers are expected to act in compliance with any prior expressed wishes of the patient or in accordance with the best interests of the patient if there were no prior expressed wishes.
Most provinces and territories have legislation that enables patients to execute an advance directive as to future care in the event they become incapacitated or unable to communicate their wishes. While anyone can execute an advance directive, these may be more common among aging adults. Physicians should be aware of this possibility and, when appropriate, discuss this with the individual or substitute decision-maker.
In treating aging patient populations, physicians will find themselves involved in end-of-life decisions. Ethical factors and clinical judgment may sometimes be at odds with the wishes of the patient or family. Disagreements between physicians and families over therapy, the withdrawal of treatment, and do not resuscitate (DNR) orders can occur.
From a medico-legal perspective, competent patients have the right to make decisions about their treatment, including DNR orders. When the patient is not competent, the appropriate substitute decision-maker should be involved in DNR decisions. Above all, any decision to issue a DNR order should never be arbitrary. The wishes and best interest of the patient are paramount when making end-of-life decisions. CMPA members can contact the Association for specific advice whenever there is a disagreement with the patient, family member, or substitute decision-maker regarding recommended treatment decisions for end-of-life care. There is also more information in the CMPA article, "End-of-life care — Support, comfort, and challenging decisions"
Contact the CMPA
As the Canadian population ages, physicians may need to adjust their practices to better meet the needs and expectations of older adults. Members are encouraged to contact the CMPA when they have medico-legal questions pertaining to the care of aging patients. The CMPA's medical officers are experienced, well informed, and can provide guidance to assist members reduce the medico-legal risks associated with treating older patients.
- "Parity refers to communication among equals. This includes avoiding what may be perceived as a paternalistic approach in language, tone and body positioning." CMPA Perspective, December 2010. "Physician-patient communication: Making it better." p. 10
- College of Physicians and Surgeons of Ontario. Age-Old Challenge: Special considerations when communicating with older patients. Accessed online on November 30, 2011
- Bell, C.M., Brener, S.S., Gunrag, N., Huo, C., Bierman, A.S., Scales, D.C., Bajcar, J., Zwarenstein, M., Urbach, D.R., "Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases," Journal of the American Medical Association (2011) Vol 306, no 8 p. 840-847
- Mosqueda, L., Dong, XinQi, "Elder Abuse and Self-neglect," Journal of the American Medical Association (2011) Vol 305, no. 5 p. 532-540. Retrieved on November 17, 2011 from: http://jama.ama-assn.org/content/306/5/532.abstract
- O'Brien, S., What are the Signs of Elder Self-Neglect? Retrieved on November 30, 2011 from: http://seniorliving.about.com/od/elderabuse/f/signs-of-elder-self-neglect.htm.