The Unbefriended Patient: An Exercise in Ethical Clinical Reasoning

Connor, Denise M.; Elkin, G. David; Lee, Kewchang; Thompson, Vanessa; Whelan, Heather K.

doi:10.1007/s11606-015-3522-0

Cited by 19 publications

(25 citation statements)

References 9 publications

(8 reference statements)

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“…Proactive efforts are also needed to identify older adults without potential surrogates (often referred to as “adult orphans”) who are at risk for becoming unbefriended and to encourage this group to engage in advance care planning and/or identify a health care surrogate. These individuals retain capacity to make their own medical decisions, but lack a surrogate decision maker or have yet to complete advance health care directives including living wills or durable power of attorney documents …”

Section: Methodsmentioning

confidence: 99%

“…Clinicians, health care organizations and other stakeholders must also proactively attempt to prevent older adults from becoming unbefriended. Older adults without potential surrogates (often referred to as “adult orphans”) are individuals who retain capacity for medical decisions, but lack a surrogate decision maker or have yet to complete advance health care directives, including living wills or durable power of attorney documents . Robust patient‐centered and interdisciplinary team‐based efforts in the community setting, through the involvement of health care professionals including but not limited to primary care physicians and social workers, are needed to assist these individuals in documenting their care preferences.…”

Section: Policy Recommendationsmentioning

confidence: 99%

“…When caring for unbefriended older adults, clinicians often rely on their own best judgment on how to proceed, with little to no oversight. For example, in a landmark study, 14% of life support decisions for unbefriended ICU patients were made without hospital or judicial oversight . Potential advantages of the clinician as decision maker include a genuine understanding of an individual's prognosis, a theoretically enhanced ability to consider what is in the patient's best interest, a sense of professional obligation and the ability to make timely decisions.…”

Section: Clinical Recommendationsmentioning

confidence: 99%

See 2 more Smart Citations

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

Farrell

Widera

Rosenberg

et al. 2016

J American Geriatrics Society

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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.

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Section: Methodsmentioning

confidence: 99%

Section: Policy Recommendationsmentioning

confidence: 99%

Section: Clinical Recommendationsmentioning

confidence: 99%

See 1 more Smart Citation

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

Farrell

Widera

Rosenberg

et al. 2016

J American Geriatrics Society

View full text Add to dashboard Cite

show abstract

“…When these mechanisms fail—in states with no default consent law, or when patients have no family or friends to serve as surrogates, or when those family and friends are unsuitable or abusive—clinicians may displace the decision to others such as hospital ethics committees. In some cases, hospitals may ask the court to appoint a decision maker through a guardianship mechanism (Castillo et al 2011; Connor et al 2016). …”

Section: Introductionmentioning

confidence: 99%

“…The prevalence of adults who are incapacitated and alone ranges from 3 to 10% of hospital and long-term care populations, affecting adults of all ages, most often older adults (Connor et al 2016; Isaacs and Brody 2010; Teaster 2002). Most clinicians report encountering these patients and participating in the medical decision-making process on behalf of such patients (Bandy et al 2010; Torke et al 2007).…”

Section: Introductionmentioning

confidence: 99%

Ethical Concerns and Procedural Pathways for Patients Who are Incapacitated and Alone: Implications from a Qualitative Study for Advancing Ethical Practice

et al. 2017

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Adults who are incapacitated and alone, having no surrogates, may be known as “unbefriended.” Decision-making for these particularly vulnerable patients is a common and vexing concern for healthcare providers and hospital ethics committees. When all other avenues for resolving the need for surrogate decision-making fail, patients who are incapacitated and alone may be referred for “public guardianship” or guardianship of last resort. While an appropriate mechanism in theory, these programs are often under-staffed and under-funded, laying the consequences of inadequacies on the healthcare system and the patient him or herself. We describe a qualitative study of professionals spanning clinical, court, and agency settings about the mechanisms for resolving surrogate consent for these patients and problems therein within the state of Massachusetts. Interviews found that all participants encountered adults who are incapacitated and without surrogates. Four approaches for addressing surrogate needs were: (1) work to restore capacity; (2) find previously unknown surrogates; (3) work with agencies to obtain surrogates; and (4) access the guardianship system. The use of guardianship was associated with procedural challenges and ethical concerns including delays in care, short term gains for long term costs, inabilities to meet a patient’s values and preferences, conflicts of interest, and ethical discomfort among interviewees. Findings are discussed in the context of resources to restore capacity, identify previously unknown surrogates, and establish improved surrogate mechanisms for this vulnerable population.

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Role of the Nutrition Support Clinician on a Hospital Bioethics Committee

2019

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Hospital bioethics committees comprise a diverse group of healthcare professionals to deal with ethical issues within the institution that arise during patient care. The nutrition support clinicians (NSCs) have an important role on a bioethics committee because of their knowledge and expertise of different nutrition routes and the benefits vs burdens and risks of these modalities, both enteral and parenteral nutrition. Ethics expertise is built on an understanding of ethical principles, when applied in clinical ethics, using critical thinking to prevent ethical dilemmas and to assist in healthcare decision making with a focus on patient-centered care. The NSCs have the opportunity to address ethics during direct patient care with their participation in the intensive care unit interprofessional rounds, family meetings, and surrogate meetings. Evident in ethical dilemmas is often the lack of advance care planning by patients and their family members concerning healthcare wishes for when the individual is unable to communicate their preferences for lifesustaining therapies, including nutrition support. NSCs, as hospital bioethics committee members, are able to support the initiative of National Healthcare Decisions Day to help educate other healthcare clinicians and the public about the importance of advance care planning with communication of healthcare wishes and completion of an advance directive. Components addressed in the article are incorporated into a comprehensive ethics case study, highlighting the role of NSCs. (Nutr Clin Pract. 2019;34:869-880) From the

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The Unbefriended Patient: An Exercise in Ethical Clinical Reasoning

Cited by 19 publications

References 9 publications

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

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

Ethical Concerns and Procedural Pathways for Patients Who are Incapacitated and Alone: Implications from a Qualitative Study for Advancing Ethical Practice

Role of the Nutrition Support Clinician on a Hospital Bioethics Committee

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