Box 27.1 Assessment of capacity to complete an LPA I interviewed Mrs Jones today. She indicated she wished to make an LPA in the favor of her husband and did not appear to be under duress from another person. She explained her health was deteriorating and she wanted her husband to manage the \200\230bills and things \200 \231 if she did not feel up to it in the future. She was able to tell me her that she owned a current account, savings account, some premium bonds, and that the mortgage had been pai d off on their house. She understood that an LPA would allow her husband to do as he wished with her money without necessarily consulting her both now and in the future. She knew tha t this power would continue even if she was too ill to be consulted. She con- \201 rmed t hat \200\230he has always sorted that sort of thing out and I don \200\231t want him to be stopped from doing it because I can \200\231t sign my checks \200\224 I trust him to do t he right thing \200\231. I believe Mrs Jones is competent to give lasting power of attorney to her husband. Dated _____________________ Signed ______________________ 660 CHAPTER 27 Ethics Making medical decisions Lasting power of attorney for health and welfare \200 This was i ntroduced in the Mental Incapacity Act in April 2005 \200 It enables nomination of an att orney to make decisions about personal welfare \200\224 usually trusted family member(s) A personal welfare LPA can only be used once the form is registered at the Of \201 ce of t he Public Guardian and the patient has become mentally incapable of making decisions about their own welfare It can include the power for the attorney to give or refuse consent to medical treatment if this power has been expressly given in the LPA (a proxy medical decision maker) Also includes power to make some social decisions, eg where the donor lives Patients who clearly lack capacity \200 Unless a valid LPA is available in the UK no one can make a decision about medical treatment for another adult without capacity \200 It is always worth enquir ing if a LPA is completed or if there is a written or verbal AD made by the patient prior to them becoming incompetent (see b \200 \230Advance directives \200\231, p.664) Doctors are required by the Mental Capacity Act to make decisions in the \200\230best inte rests \200\231 of their incompetent patients, and this holds true even if there is a valid LPA In America a hierarchy of next of kin can legally make substitute decisions. Relatives are often surprised and occasionally angry to \201 nd that they have few rights in the UK In practice doctors should routinely consult next of kin where important or contentious medical decisions are made for patients without capacity. The huma n rights legislation, through its support of \200\230family life \200\231 as a basic human right will reinforce the social shift towards increasing power for relatives. Relatives ca n help doctors to decide what the patient might have wanted under the circumstances, assist ing decisions about best interest If there is con \202 ict between the medical team and relatives about what is in the best interests of the patient that cannot be resolved the doctor involved ma y wish to seek a second medical opinion, consult with the hospital legal team, an IMCA, or refer to the courts Patients who may or may not have capacity \200 Patients \200\231 views should always be s ought about medical treatments \200 Often these views will concur with those of the medic al professional, or they are happy to be guided by the doctor Rarely, a patient will express a view at odds with either the medical team or their family, in which case a careful assessment of capacity to make their own deci sion is required Assess capacity in line with the principles outlined previously and document meticulously i n the notes (see example in Box 27.2 ) see b \200\230Making complex decisions \200\231, p. 667 MAKING MEDICAL DECISIONS 661 Box 27.2 Assessment of patient refusing a colectomy for cancer Miss Joseph has told me she will not consent to a colectomy. I have explained the procedure that is being recommended including the ben- e \201 ts and risks and she has been able to remember and understand this information without dif \201 culty. She explains that in vie w of her age and lack of current symptoms she would rather not put herself through a major operation. She said \200\230I am 79 years old and I don \200\231t want to be mucked around \200\231. She understands that by refusing surgery she might be shortening her life and th at she may become ill in the future as the tumor grows but feels that this is a \200\230le sser evil \200\231 than an operation at the moment. I believe she has capacity to make this decision and we have agreed to discuss it again in two weeks time during an outpatient app ointment after she has spoken to her family. Dated ______________________ Signed ______________________ 662 CHAPTER 27 Ethics Making social decisions The legal position for social decisions for patients without capaci ty (eg where a patient should live) is the same as for medical decisions. Unless an LPA is in place, the healthcare team should consult with family to try to ensure that the patient \200\231s best interests are met. If making a decision against the expressed wishes of patient without capacity, involve an a dvocate. Where there are no family members, or there is a lack of support for the patient, an IMCA may be appropriate ( see b \200\230The Mental Capacity Act 2005 \200\231, p.656). The DoLS should be followed (see b \200\230Deprivation of Liberty Safeguards \200\231, p.6 57) and these demand that decisions are made \200\230the least restrictive \200\231. It may be necessary to apply to the Court of Protection for a court appointed deputy to supervise welfare decisions. A very common challenge for the geriatric MDT is the patient who wants to continue to live alone in their own home after they have developed physical or cognitive problems which mean they are at risk in that environment (see b \200\230HOW TO Manage a patient insisti ng on returning home against advice \200\231, p.663). Further reading Lowe M, Kerridge IH, McPhee J, et al. ( 2000 ). A question of competence. A ge Ageing 29 : 179 \200\223 82 . MAKING SOCIAL DECISIONS 663 HOW TO Manage a patient insisting on returning home against advice First assess whether the patient has capacity to make the decision: \200 Patients with ca pacity should accept that they are at risk and reason that they prefer to take this risk th an accept other accommodation \200 In borderline or contentious cases a second opinion, o ften from a psychogeriatrician, can be helpful If the patient has capacity then they cannot be forced to abandon their home or accept outs ide help although the healthcare team and family can continue to negotiate and persuade. \200 It is worth determining what motives lie behind the patient \200\231s insistence; som etimes misconceptions can be corrected Patients will sometimes agree to a trial period of residential care or care package and this often leads to long-term agreement Where the patient lacks capacity , decisions should be made in the patient \200\231s best i nterest, and be the least restrictive option. While the patient should not be discharged to an environment where they will be at unreasonable risk, the team should still attempt to a ccommodate the patient \200\231s wishes and steps may be taken to reduce risk (eg discon- n ecting or removing dangerous items, alarm systems, or regular carer visits, etc. may still allow a patient to return home). There is no such thing as a \200\230safe \200\231 dischar ge \200\224 only a safer one. Finally ensure you record your capacity assessment clearly, eg: Mr King has been a patient of mine for 2 years. He has a progressive dementia which is now severe and concern has been expressed by his son and the carers that he is at risk to himself in continuing to live al one at home. He was admitted to hospital on this occasion after a small house \201 re (he left an unattended pan on the stove). He has had three other admissions since Christmas wi th falls and accidents. Over the last 2 weeks I have had several discussions with him about why his family is concerned about him. The nurses, his son, and his home carers have also had such discussions. When I spoke to him today he was disoriented in person and place (bel ieving he was in a police station and that I was a policeman). He expressed a wish to go ho me to be with his wife (who died 12 years ago) but could not tell me his address. He did no t believe that there were any risks involved in going home and did not accept that there wa s a possibility of falling over again saying \200\230I am a very strong man, you would be more likely to fall over than me. \200\231 When I discussed the \201 re he started talkin g about his war-time experiences and would not accept that there was a risk of \201 res i n the future. At present I believe that Mr King lacks capacity to make a valid decision abo ut his social circumstances. I have no reason to believe that his level of competency will improve with further education or time. A multidisciplinary case conference has been arrang ed for next week to discuss if it is practical to continue to support him in his own home o r whether placement should be sought. Dated ____________________ Signed ____________________ 664 CHAPTER 27 Ethics Advance directives \200 An AD (also known as advance decision) is a patient-led medical decision, made when the patient is competent, which is designed to come into force if a pat ient becomes incompetent \200 ADs were developed to promote personal autonomy \200 They may be verbal statements but are more commonly written (sometimes known as a living will) ADs are usually employed by patients to refuse aggressive treatment but could, theoreticall y, be used to request or direct treatment. However ADs cannot be used to request treatment which would not usually be offered or to withdraw \200\230basic care \200\231 (eg nursing or analgesia) \200 A valid AD holds the same weight in law as a contemporaneous patient d ecision and doctors who provide a rejected treatment could be sued for battery. However a d octor must \201 rst assess whether an AD is valid and applicable (see b \200\230HOW TO Assess whether an AD is valid and applicable \200\231, p.665) A template AD can be downloaded from the Compassion in Dying charity website ( M www.compassionindying.org.uk ) The UK Mental Capacity Act clari \201 es the legality of ADs. In an emergency if an AD is not provided or if there is doubt about the legitimacy of an AD then clinically appropriate treatment should be provided. Where a health- care professional has a conscientious object ion to implementing a valid AD the care should be handed to another practitioner. Despite t he theo- retical advantages of ADs for patients, relatives, and the medical team they are s till rarely seen in clinical medicine. There are several barriers to their successful imple mentation: \200 Patients are often unaware of ADs or their legal validity \200 Patients and doctors are often reluctant to confront these distressing topics or feel that the other party should initiate discussions The transfer of AD from primary care, family homes, and solicitors (where they are often composed and lodged) to hospital (where they are most commonly design ed to be implemented) is often poor \200 Concern that views might change in future altere d states of health \200 ADs may be too vague to inform physicians, eg a refusal of \200 \230life sustaining treatment \200\231 may not help with decisions about iv \202 uids, etc. \200 A high level of competence is required to complete an AD. Patients with conditions such as Alzheimer \200\231s disease have commonly lost the ability to make one by the time of diag nosis Ideally an AD forms part of the wider process of advance care planning between a patient an d the health care professionals, being promoted by the UK Gold Standards Framework ( M www. goldstandardsframework. nhs.uk/AdvanceCarePlanning ). AD are most likely to be useful when there is a predictable course of illness (disease-spec i \201 c advanced directives have been used in AIDS, cancer, MND, and COPD) ADVANCE DIRECTIVES 665 HOW TO Assess whether an AD is valid and applicable If a patient retains capacity then you should discuss management deci- sions with them in t he usual way. An AD is not an excuse for avoiding, often emotionally dif \201 cult, discus sions with patients or relatives. Contemporaneous decisions always outweigh a previous AD. As long as an AD is valid and applicable, it should usually guide treatment. This was true under common law before the Mental Capacity Act but the conditions of validity and applicab ility are now more clearly de \201 ned. Verbal statements are theoretically valid but it is much harder to ensure that they are cor rectly relayed and refusal of life-sustaining treatment must be written. Ensure that the AD was not been given under duress or pressure from a third party. It is necessary to assess if the patient had capacity at the time the AD was created (both capacity to make an AD and capacity in terms of understanding the pros and cons of the medi cal treatment they are refusing) and this can be very dif \201 cult to assess. If the AD is applicable then the circumstances should be the same as those de \201 ned in the AD The Mental Capacity Act now de \201 nes when an AD is legally enforceable. The following conditions must be met: \200 Written statements must be signed and dated \200 Must have at least one signature from a witness who is not a relative, LPA, or bene \201 ciary of the will If the AD refuses life-sustaining treatment there must also be a statement to verify that the decision applies to treatment \200\230even if life is at risk \200\231 The AD must be valid and applicable \200 If a health and welfare attorney has been appoin ted under a LPA, this attorney should also be involved in discussions about the person s tr eatment, and doctors should take information provided by him or her into account. An AD ove rrides a LPA, unless an LPA prepared after the AD speci \201 cally confers authority on th e attorney. Further reading Advance statements about medical treatment. ( 1995 ). Code of Practice with Explanatory Notes. London : BMA . GMC guidance (6858) . Treatment and Care Towards the End of Life: Good Practice in Decision Making. Online: M http://www.gmc-uk.org/guidance/ethical_guidance.asp . 666 CHAPTER 27 Ethics Diagnosing dying and estimating when treatment is without hope A high percentage of elderly patients admitted to hospital are destined to die despite best medical care. A great deal of \201 nancial and human resources and most importantly patient suffering could be avoid ed if this death was predictable. The art of applying treatment aggressively when appropria te but backing off compassionately in other circumstances is one of the most common and cha llenging tasks in geriatric medicine. There has been a lot of discussion about do not attempt cardiopulmonary resuscitation (DNAC PR) orders but decisions about less dramatic life-saving technologies are just as hard (eg whether to admit a patient from a nursing home for iv antibiotics and \202 uids or select ing patients for renal replacement therapy (see b \200\230Renal replacement therapy: dialy sis \200\231, p.396) or when to initiate arti \201 cial nutrition (see b \200\230The ethi cs of clinically assisted feeding \200\231, p.360). Unfortunately predicting futile treatment is fraught with dif \201 culty \200\224 experie nced doctors never underestimate the power of some older people to make a miraculous recove ry. The following tips may help: \200 Attempt to make a diagnosis (which usually requires some investigations and minor procedures) before estimating prognosis Consider a trial of treatment but constantly monitor the clinical response and be willing to up or down regulate how aggressively to treat \200 Sometimes it is help ful to de \201 ne limits at the onset of treatment (eg oral but not iv therapy, a 2-week t rial of NG feeding in a patient following stroke, a 20-unit maximum transfusion for acute g astrointestinal bleeding) Decide about each intervention separately \200\224 every procedure and patient will have different risk/bene \201 t and tolerability ratios \200 If there is do ubt or disagreement about the appropriateness of treatment seek a second medical opinion Remember that medical decisions are not made in isolation \200\224 relatives, nurses, ther apists, and community carers are ultimately affected by such decisions and open dialog will help everyone The patients \200\231 wishes are paramount but many severely ill patients do not have capac ity to make decisions. Beware patients who reject treatment out of ignorance, misconception s or fear. Likewise patients or relatives who continue to demand treatment which is clearly not effective (or inap- propriate) require education and support. Deciding that treatment is futile is not the same as \200\230giving up \200\231 \200\224 a positive decision for terminal care allows a change in the therapeutic goal from \200 \230cure \200\231 to \200\230keeping comfortable \200\231 and ensuring a digni \201 ed de ath. While in some branches of medicine this shift can involve a change in environment (eg to hospice) and medical team (to community or palliative care team) in geriatric medicine t he line is often blurred, see b \200\230Palliative care \200\231, p.642. The use of the Li verpool Care Pathway ( M www.mcpcil.org.uk ) is becoming more widespread, and provides a st ructure for quality end-of-life care. Further reading GMC guidance (6858). Treatment and Care Towards the End of Life: Good Pract ice in Decision Making. Online: M http://www.gmc-uk.org/guidance/ethical_guidance.asp . MAKING COMPLEX DECISIONS 667 Making complex decisions All complex decisions should be made with the following in mind: \200 The patient should be presumed to have capacity unless proven otherwise and as such s hould be at the center of the process \200 Efforts should be made to optimize decision ma king capacity \200 All decisions should be in the patient \200\231s best interests \200 Wide communication avoids misunderstanding at a later date Use the \202 ow chart in Fig. 27.1 as a guide. Medical team make a clinical judgment, considering the patient \200\231s views and beliefs Does the patient have capacity? Yes No Is there a proxy decision-maker appointed by LPA? Explain options clearly, outlining risks, burdens and benefits. Be honest where there is un certainty. Ensure there is understanding and support decision-making. If there is disagreem ent about the decision, explore the reasons and ensure the choice is informed. Remember a p erson has the right to make a seemingly unwise decision. Yes No Make a decision in the patient \200\231s best interest. Involve family and friends to infor m about patient \200\231s previous views. Consult other health care professionals. Independ ent advocates may be useful (IMCAs) If there is disagreement about the decision, attempt to resolve locally seeking advice from a more experienced colleague, obtaining a second opinion, using an independent advocate, h olding a case conference, or using local mediation services. If problems persist, involve t he appropriate legal body Fig. 27.1 Flowchart for making complex decisions. 668 CHAPTER 27 Ethics Cardiopulmonary resuscitation CPR was \201 rst described in 1967 and is now widely applie d both in and out of hospital. Around 20 % of those who die in hospital in the UK will have at least one attempt at CPR during their terminal admission. Although the principles of CP R decisions are the same as for other medical decisions they demand special attention becau se: \200 Cardiac arrest often occurs unpredictably \200 Withholding CPR in a cardiac ar rest will most likely lead to death \200 There is an assumption that all patients will re ceive CPR in hospital \200\224 unlike most treatments a decision is required to withhold it CPR is a highly emotive subject CPR is undoubtedly a life-saving procedure (in hospital aro und 20 % will recover a pulse and half of these patients will survive to leave hospital). T hose who survive CPR have a reasonable life expectancy but a small per- centage (1 \200\223 2 % ) will be left with permanent hypoxic brain damage. Predicting outcome for CPR (Table 27.2) \200 Highest success rates are obtained treating arrests due to cardiac arrhythmia on coronary care units, lowest on general medical wards in frail patients with m ultiple pathologies Older patients have lower survival rates but this is probably a feature of their multiple p athologies and a good outcome is possible if older patients are carefully selected Individual pre-arrest factors are not sensitive or speci \201 c enough to be useful in pre dicting outcome. Morbidity scores combine several variables to attempt to predict outcome o f CPR more accurately but are not in common use Table 27.2 Factors that predict outcome after CPR Worse survival rate Better survival rate Pre-arrest Hypotension Myocardial infarction Uraemia Malignancy Heart failure Pneumonia Homebound lifestyle Peri-arrest Out-of-hospital arrest In hospital arrest Unwitnessed arrest Witnessed arrest Asystole or electromechanical dissociation (EMD) Ventricular \201 brillation Post-arrest Long duration of CPR Short duration arrest Slow to waken Quick to regain consciousness Further reading Prognostic Indicator Tool. online: M www.goldstandardsframework.nhs.uk . This page intentionally left blank 670 CHAPTER 27 Ethics The process of CPR decision making In some circumstances it is appropriate to decide agains t doing CPR in the event of a cardiopulmonary arrest. These decisions are known as do not a ttempt CPR, or do not attempt cardiopulmonary resuscitation (DNACPR) or allow natural death (AND) decisions. There has been much discussion about the best way of approaching this, with sometimes con \202 icting views from those in favor of patient autonomy and those who feel this is a medi cal decision, with many guidelines published. The 2010 UK GMC guidance \200\230Treatment a nd care towards the end of life: good practice in decision making \200\231 offers a sensibl e balance ( M www.gmc-uk.org ). When to consider a DNACPR order \200 Where attempting CPR will not restart the patient \200\231s heart and breathing (medical futility) Where there is no bene \201 t in restarting the patient \200\231s heart and breathing (quality or length of life) Where the expected bene \201 t is outweighed by the burdens of CPR \200 Where a patient with capacity has decided this is what they want It may be reasonable to only make decision s for those patients in whom arrest seems likely (eg critically unwell, actively dying) alt hough facilities with limited out-of-hours cover may make more prospective decisions. Where no DNACPR decision is made, the presumption is that resuscita- tion should be attempted. Where CPR is clearly futile \200 A doctor cannot be compelled to provide a futile treatme nt, and so this is a largely medical decision, although remember that \200\230futility \200\231 is rarely clear-cut Carefully consider whether it is necessary or appropriate to tell the patient that a DNACPR decision has been made \200\224 balance possible wish to know with the burden of discussi ng something that is not clinically relevant In general it is good practice to inform patients with capacity (or at least offer to discu ss the issue and be guided by response) and to discuss with interested parties/proxy decisi on-makers for patients who lack capacity. If a DNACPR order is to be recorded on patient he ld or accessible records it could be detrimental if they were not aware of the order in adv ance Where CPR may be successful \200 If CPR may be successful, but outcome may be poor, then a decision made in the best interests of the patient should involve their personal view of that outcome For patients with capacity, a careful discussion should be had, outlining the risks, burden s and bene \201 ts of CPR (see b \200\231HOW TO Manage DNACPR decisions \200\231, p .671) For those who lack capacity, their views should be approximated from family and friends. Ot her healthcare professionals should be consulted and an independent advocate (IMCA) may occ asionally be useful THE PROCESS OF CPR DECISION MAKING 671 HOW TO Manage DNACPR decisions Ensure you know the local guidelines. Hospitals vary in how this deci- sion is made, record ed and who is authorized to make DNACPR. Busy physicians need to make time for DNACPR decis ions, although they often prove to be easier than anticipated: \200 Although it could tak e 30min to get an elderly patient to make a fully informed decision (many have not even heard of CPR) you can often get a fairly accura te idea from a competent patient with a few quick questions like \200\230are you the kind of person that wants everything done/nature to take its course \200\231 Never ignore patient cues, eg \200\230I don \200\231t suppose I will come out of this? \200\231 or \200\230I \200\231ve had my time \200\231. These are ideal times to disc uss end-of-life issues and such patients are often relieved by this \200 Experienced nurs es will often provide helpful guidance In reality, the majority of DNACPR decisions on geri atric wards will not involve the patient (because of incapacity) so lengthy meetings with r elatives may ensue to establish best interest: \200 When sensitively handled there is rar ely con \202 ict and many are relieved to be consulted or happy to be guided by the doctor \200\231s opinion Try to use the time to discuss general management (emphasizing positive management steps \201 rst \200\224 even if that is just maintaining dignity and comfort) so that the family doesn \200\231t perceive the only medical priority is avoiding CPR Where con \202 ict does arise it can be best to leave the patient for CPR and re-address t he question later. Relatives often take some time to trust the doctors, to come to terms, o r to consult other family/ friends and often the con \202 ict melts away. Remember, CPR is only a small fraction of the patient \200\231s care and it may distract from other more im portant things. While this might lead to a rise in unsuccessful CPR attempts (with conseque nt reduction in morale of resuscitation teams and resource implications) it does protect pa tient autonomy and doctors from complaints/litigation No one can be forced to provide a treatment which they feel is inappropriate so if there is conscientious objection to providing CPR consider moving the p atient to a different doctor/ward Recording a DNACPR decision \200 Write the decision prominently in the medical notes \200 Many institutions have a speci \201 c form to record these decisions, but ensure that any relevant discussion is fully documented Sign, date, and time clearly \200 Document the rationale for the decision and the names o f those consulted in making the decision If the patient was not consulted the reason should be listed The responsible consultant sho uld endorse a DNACPR order made by a junior doctor as soon as possible. 2Ensure that nurses are aware as soon as a DNACPR order is made. 672 CHAPTER 27 Ethics Rationing and ageism Rationing \200 This has been present in the NHS since its inception in 1948 but the ever-increasing cost of modern specialized, technological, and pharmacologi cal medicine, along with the growing sophistication of patients has meant that recently rat ioning has become more explicit and contentious No UK government has ever openly admitted to rationing although \200\230cost-ef \201 cien cy \200\231 and \200\230budgeting \200\231 are thinly disguised way of handling dif \201 cult rationing decisions The level at which rationing decisions are made has gradually moved up from physicians them selves (which led to considerable inequality), to hospital managers (which did not remove r egional inequality). The introduction of NICE (National Institute for Health and Clinical E xcellence) in 1999 was designed to help make rationing decisions at a national level by set ting guidelines Some initial NICE recommendations that treatments should not be funded (eg interferon B in multiple sclerosis) led to signi \201 cant lobbying and the dev elopment of risk-sharing schemes (allowing government and drug manufacturers to share the c ost in certain cases) \200 In other cases funding has been advised (eg glycoprotein IIb/I IIa inhibitors in acute coronary syndromes) but this has not led to widespread implementati on. So-called \200\230postcode prescribing \200\231 refers to the variable availability of drugs depending on health authority or GP boundaries Ageism This is rationing applied by age criteria. Although the UK National Service Framewor k ( see b \200\230The National Service Framework for Older People \200\231 , p.28) has ban ned explicit rationing (standard 1 states \200\230NHS services will be provided, regardles s of age, on the basis of clinical need alone \200\231) it is still widespread. It is accepted that some medical interventions, eg ITU may be less effective when applied to older people, but remember: \200 Some older people are physiolo gically younger (ie chronological age does not correlate well with biological age). Age is not a good guide to frailty Some treatments (eg thrombolysis in MI) save more lives in an older age group (number neede d to treat is lower because untreated death rate is higher than in younger groups) Disability and dependence costs the state dearly; preventing strokes, operating on severely osteoarthritic hips, etc. are often highly cost-ef \201 - cient interventions if they ena ble patients to stay at home rather than go into costly institutional care (quite apart fro m the bene \201 t to the patient). There is good evidence that the average patient uses th e majority of healthcare resources in the last year of their life but it is rarely possible to predict prospectively when patients are entering their terminal year, nor RATIONING AND AGEISM 673 is there evidence that voluntary restriction of medical treatment by ADs (see b \200\230Ad vance directives \200\231, p.664) has any cost-cutting effect. There is a more fundamental ideological principle that sectors of the population who are pe rceived to have less social worth, are less likely to complain, and are largely politically inactive should not be discriminated against \200\224 whether those sectors are de \201 ned by age, sex, or race. The commonly quoted \200\230fair innings \200\231 argument sugge sts that after a certain age you have had your \200\230share \200\231 of world resources a nd younger patients should therefore take precedence. Older people commonly hold to this ph ilosophy. This method of rationing assumes that everyone uses equal resources and enjoys eq ual quality of life up until the point that it \200\230runs out \200\231. The logical cons equence is that high users of resources (eg people with diabetes) should have had their fai r innings at a much younger age. In reality society accepts that some of it members will ta ke more than they give to the system \200\224 it is prejudice that allows us to accept rat ioning for older patients but not for a child with cerebral palsy. Further reading NICE online : M www.nice.org.uk . National Service Framework for Older Peop le ( 2001 ) online: M http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/Publi cationsPolicyAndGuidance/DH_4003066 . The rationing debate. BMJ 1997 ; 314 : 820 (case for) and 820 (case against) . 674 CHAPTER 27 Ethics Elder abuse De \201 ned as any act, or lack of action that causes harm or distress to an o lder person. Under-recognized, with few prevalence studies. One esti- mated around 5 % of c ommunity dwelling older people have suffered verbal abuse, and 2 % physical abuse. Probably more prevalent within care homes, but precise extent unknown. Types of abuse Psychological \200 Bullying, shouting, swearing, blaming, etc. \200 Look for signs of fear, helplessness, emotional lability, ambivalence toward caregiver, withdrawal, etc. Physical \200 Hitting, slapping, pushing, restraining, etc. \200 May also include inapp ropriate sedation with medication \200 Look for injuries that are unexplained, especially if they are different ages, evidence of restraint, excess sedation, broken glasses, etc. Financial \200 Inappropriate use of an older person \200\231s \201 nancial assets \200 Includes using checks, withdrawing money from an account, transferring assets, taking jewelry or other valuables, failing to pay bills, altering will s, etc. Sexual \200 Forcing an older person to participate in a sexual act against their will \200 Look for genital bruising or bleeding, or sexual disinhibition Neglect \200 Depriva tion of food, heat, clothing, basic care \200 Occurs in situations where an older person is dependant \200 Look for malnutrition, poor personal hygiene, and poor skin condition \200 Easier to spot in situations where a certain standard of care is anticipated (eg patients from care homes being admitted to hospital who are unkempt, dirty, or inappropriately dressed may raise concerns) Who abuses? \200 Commonly someone in a caregiver role \200 Often arises because of care r anger, frustration, and lack of support, training or facilities along with social isolation Relationship dif \201 culties between carer and recipient, and carer mental illness or substance misuse (eg alcohol) exacerbate the situation Sleep deprivation or dealing with fecal incontinence may also precipitate abuse 2Most are under extreme stress ( \200\230at the end of my tether \200\231) and extremely re morseful afterwards. ELDER ABUSE 675 HOW TO Manage suspected elder abuse The UK Government \200\231s \200\230No Secrets \200\231 guidance, published in 2000, aims to identify \200\230vulnerable adults \200\231 who should be the focus of local safeguardi ng policies and procedures. The term \200\230safeguarding \200\231 means a range of activ- ities aimed at upholding an individual \200\231s fundamental right to be safe and local pr otocols should be in place, under the guidance of safeguarding adults boards. The following is a guide: An individual does not have to prove abuse to take action, only have a strong suspicion that it is occurring The \201 rst step is to involve other agencies \200\224 this may include social services, involved agencies (eg home carers), the general practitioner, the local health au thority and (rarely at \201 rst) the police \200 Assessment of the carer and recipient should be detailed, multiagency, and individually tailored As abuse is usually as a result of caregiver stress, a common approach is to attempt to relieve that stress (eg providing home care, day care, respite ca re, health support, advice about sleep or continence, \201 nancial help, rehousing, etc.) while maintaining the patient at home Close multidisciplinary supervision is essential until the situation improves Removal of the patient from an abusive situation may occasionally be done using laws design ed primarily for other purposes, eg the Mental Health Act (provision to act in the best int erests of patients with mental illness) Police involvement may occasionally be necessary where there are no remediable factors or a very high risk of future harm Further information is available f rom the following UK charities: Action on Elder Abuse \200\224 M www.elderabuse.org.uk \200 Age Concern \200\224 M www. ageuk.org.uk This page intentionally left blank 677 Chapter 28 Finances Making a will 678 Taxation 679 Pensions 680 Bene \201 ts 682 678 CHAPTER 28 Finances Making a will \200 Everyone over 18 should make a will. This need not be complicated \200\224 there are cheap will writing \200\230kits \200\231 available to buy, and forms can be down loaded from the Internet even more cheaply, eg M http:// freeguard.co.uk/aboutus.aspx The will should be kept in a safe place, and family members informed \200 Wills that are more complex should be made through a solicitor \200 It is common for the question of wil ls to arise for the \201 rst time when someone becomes ill, often in hospital Doctors may become involved where there is doubt about the patients capacity to make a will Capacity (competence) is covered in detail elsewhere (see b \200\230Capacity \200\231, p.654). It is decision-speci \201 c so must be reassessed for each important decision a person makes Testamentary capacity This is de \201 ned in England and Wales by a speci \201 c set of l egal criteria. These criteria were established in the 1870 court case of Banks v Goodfellow . A person drawing up a will must: 1. Understand the nature of the act and its effect \200\224 ie know that they are choosing whom to give their property to after death 2. Understand the extent of the property being willed \200\224this need not be precise, bu t the person should know roughly what they are willing (eg a house and savings) along with details of any joint ownership and debts. The larger the estate, the clearer this understan ding should be 3. Understand the nature and extent of claims on them \200\224 both include d and excluded parties. This means the person should be able to say who might reasonably ex pect to bene \201 t from their will (spouse, children, etc.) and if people are excluded, g ive reasons why 4. Have no mental disorder directly in \202 uencing points 1 \200\2233 \200\224this does not mean that a will cannot be made if someone has a mental disorder \200\224 rather that this is not coloring his or her speci \201 c testamentary capacity. This can be hard to pr ove, but an example may be where a demented patient develops paranoid delusions about a car ing spouse, and excludes him or her from the will as a result 5. Be under no undue in \202 uence from third parties \200\224 this again may be hard to prove except in very overt circumstances It is sensible to assess capacity at the time the will is drawn up, and then brie \202 y c heck at signing (these can be some time apart). A doctor asked to assess testamentary capacity should question the person with direct refer ence to Banks v Goodfellow criteria, and make clear contemporaneous notes (with direct quot es) that support the conclusions drawn. It is probably better to avoid being a witness to a will signing for patients in your care (this can be done by anyone), as this may be confused with a formal capacity assessment. Further reading Posener HD , Jacoby R ( 2002 ). Testamentary capacity . In: Jacoby R , Oppe nheimer C (eds) Psychiatry in the Elderly , 3 rd edition. Oxford : Oxford University Press , pp. 932 \200\223 40 . TAXATION 679 Taxation \200 Most income received by older people in the UK is taxed \200 The allowanc e of tax-free income rises with age \200\224 in 2011, people under 65 can have an income of 7475 per annum without paying tax, whereas this \201 gur e rises to 10,090 age 75 and over