AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults

Abstract

In this position statement, we define unbefriended older adults as patients who: (1) lack decisional capacity to provide informed consent to the medical treatment at hand; (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and (3) lack family, friends or a legally authorized surrogate to assist in the medical decision‐making process. Given the vulnerable nature of this population, clinicians, health care teams, ethics committees and other stakeholders working with unbefriended older adults must be diligent when formulating treatment decisions on their behalf. The process of arriving at a treatment decision for an unbefriended older adult should be conducted according to standards of procedural fairness and include capacity assessment, a search for potentially unidentified surrogate decision makers (including non‐traditional surrogates) and a team‐based effort to ascertain the unbefriended older adult's preferences by synthesizing all available evidence. A concerted national effort is needed to help reduce the significant state‐to‐state variability in legal approaches to unbefriended patients. Proactive efforts are also needed to identify older adults, including “adult orphans,” at risk for becoming unbefriended and to develop alternative approaches to medical decision making for unbefriended older adults. This document updates the 1996 AGS position statement on unbefriended older adults.

Ethical Challenges in Caring for Unrepresented Adults: A Qualitative Study of Key Stakeholders

“…Moye et al, in their conclusion, advocated for multiple stakeholder involvement to ensure more perspectives in the decision‐making process . This study is in agreement with such calls for more guidance on decision making for these patients and stakeholder collaboration …”

“…Our study adds further detail about ethical challenges encountered in the care of unrepresented adults in a safety net setting and across multiple professions. As noted by the AGS Position Statement, identifying ethical challenges is only one step; others include addressing ethical issues explicitly, promoting procedural fairness, and using a team‐based approach to incorporate unrepresented adults' preferences into treatment decisions . Our participants made similar recommendations.…”

“…Ethical challenges that arise in the care of unrepresented adults have long been recognized and force us to solve tensions between foundational concepts in bioethics, such as autonomy and beneficence . However, there remains a small amount of literature on the prevalence of these challenges and addressing them or examining the relevance of other theoretical frameworks in bioethics (eg, ethics of care) . Even the terminology is still evolving, from “adult orphan” or “unbefriended” to “unrepresented,” which we use here .…”

“…When the physicians are the decision makers, evidence shows they make decisions based on their own professional and personal values, rather than considering the patient's values . In 2016, the American Geriatrics Society (AGS) highlighted the practical challenges of caring for these patients, including the potential for ethical transgressions . A recent qualitative study highlighted the complexity of caring for unrepresented adults in Massachusetts in hospitals and long‐term care, including the number of multisector stakeholders, such as healthcare and the courts, and related ethical concerns …”

Advance Care Planning in Cognitively Impaired Older Adults

“…There is heightened urgency in having ACP discussions with “un‐befriended” older adults with cognitive impairment. These are people who lack decisional capacity to provide informed consent to a particular medical treatment; have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and do not have family, friends, or a legally authorized surrogate to assist in the medical decision‐making process . Ensuring a dignified, person‐centered decision‐making process for an un‐befriended individual requires close collaboration between the individual, healthcare providers, and knowledgeable interdisciplinary team members (e.g., social workers, medico‐legal colleagues, ethicists) .…”