Routine “rescue” care for the frail elderly is unethical
On a daily basis both in hospitals and in our offices we deploy a dizzying array of medications and technologies designed to extend life. The problem is that most of these interventions have rarely been tested on frail seniors and have a much greater chance of causing them harm than providing benefit. Yet “rescue” care for frail seniors continues to be routine – a practice that violates the ethical standard of informed consent.
Frailty is a “multidimensional syndrome of loss of reserves (energy, physical, ability, cognition, health) that gives rise to vulnerability”. Younger seniors generally speaking, are not frail. In fact, Canadian seniors 65 to 75 years old report limitation in activities of daily living similar to those adults aged 45 to 64 years.
However one quarter of seniors 85+ report moderate to severe functional limitation and the overall weighted prevalence of frailty in older seniors is about 30%. Dementia is an important element of frailty with the stages of mild, moderate and severe dementia mirroring those of frailty.
Far more than age, frailty predicts poor prognosis, limited lifespan, a higher rate of surgical complications and longer hospital stays. While the extraordinary advances of modern medicine work well for middle-aged adults and seniors who are not frail, for frail seniors these interventions are far more likely to cause harm than provide benefit. Many elective procedures such as angioplasty, knee replacements and colonoscopy have a much higher rate of post-intervention delirium with prolonged hospitalization followed by admission to residential long term care, when practiced on frail seniors. Frailty, much more than age, predicts this outcome.
And yet we rarely recognize frailty and dementia as an independent risk factor. It takes time to carefully gather the necessary information to understand if frailty is present. Even when we do recognize the presence of frailty, we often fail to educate seniors or their families about what to expect.
When a frail older person comes into the emergency department or presents to our offices, we simply do what we are trained to do which is try to fix each broken-down part. We apply our medical decision rules and algorithms for each disease to that person. In many ways, it is much easier to do this than the careful digging required to diagnose and stage frailty, to say nothing of having the difficult conversations with patients and their families about the prognosis associated with frailty. In his most recent book American surgeon Atul Gawande observes that doctors don’t know when to stop intervening and patients don’t know how to tell them to stop.
However, without determining how much frailty is present and the associated prognosis, we are withholding crucial information for seniors and families to make informed decisions. Simply proceeding down a given “rescue” pathway without providing this information is a gross failure to provide informed consent and arguably unethical.
Drs Paige and Moorhouse, two geriatricians from Halifax who have studied decision-making in this demographic, write that all frail seniors have a right to good information about the following questions: “Which health conditions are easily treatable, and which are not? Is there frailty and how will frailty make treatment risky? How can symptoms be safely and effectively managed? Will the proposed treatment improved or worsen function or memory? Will the proposed treatment require time in hospital and if so, for how long? Will the treatment allow more good quality years, especially at home? and What can we do to promote comfort and dignity in the time left?”
Given a better understanding of the prognosis of frailty there is strong evidence that many would opt for not proceeding with life extending intervention. It should be the right of seniors and their families to be adequately informed about their degree of frailty and what to expect. Without providing them this information, “rescue” care for these frail seniors is unethical.
Margaret McGregor is a Vancouver family physician and director of Community Geriatrics with the UBC Department of Family Practice.