Geriatrics Ethico-Legal Considerations PDF

1st Semester October 2024 GERIATRICS NCMB314 Ethico-Legal Considerations/Ethical P...

1st Semester October 2024 GERIATRICS NCMB314 Ethico-Legal Considerations/Ethical Principles ETHICAL PRINCIPLES Omission or commission of an act that departs from ▪ Between a guardian, conservator or other lawfully acceptable and reasonable standards, which can take designated agent and the elder’s wishes and interests several forms. ▪ Between a caregiver’s business interests and the elder’s ◦ MALFEASANCE: committing an unlawful or improper act. interests. Well-being and quality of life. ◦ MISFEASANCE: performing an act improperly PERCEIVED CONFLICTS OF INTEREST: which include those ◦ NONFEASANCE: failure to take proper action which are not actual conflicts in the course of care but may ◦ MALPRACTICE: failure to abide by the standards of one’s later become conflicts when the elder patient’s interest profession diverge from those who provide the care. ◦ CRIMINAL NEGLIGENCE: disregard to protection the safety ISSUES ON CONFIDENTIALITY of another person In caring for an elderly patient, invariably, there is disclosure ETHICS OF CARE made by the family and relatives regarding information that include compassion, equity, fairness, dignity, confidentiality, may otherwise be personal and confidentiality to the patient and mindfulness of a person’s autonomy within the realm of alone. the person’s abilities and mental capacity. ISSUES ON DECISION-MAKING CAPACITY ◦ ADVOCACY: refers to loyalty and a championing of the Many times, the older patient’s decision-making capacity needs and interest of others, to educate and informed the (also referred to as “ competence”) may be required for patients about their rights and access benefits entitled for certain decisions. them LEGAL RISKS IN GERONTOLOGICAL NURSING ◦ AUTONOMY: is the concept that each person has a right Malpractice to make independent choices and decisions. Confidentiality ◦ BENEFICENCE/NONMALEFICENCE: These concepts of do Patient consent good (beneficence) and do no harm (nonmaleficence) are Patient competency integral to health care. Staff supervision ◦ CONFIDENTIALITY: Emphasizes respect for human dignity Medications that is demonstrated in daily work. Restraints ◦ FIDELITY: Refers to keeping promises or being true to Telephone orders another, being faithful to commitments and Do not resuscitate orders responsibilities. Advance directives and issues related to death and dying ◦ FIDUCIARY RESPONSIBILITY: Refers to using both fiscal Elder abuse reserves and caregiving resources wisely, potentially BENEFITS AND PRIVILEGES OF “SENIORS” requiring a cost-benefit analysis to facilitate decision REPUBLIC ACT 7432 making. Known as “an act to maximize the contribution of senior ◦ JUSTICE: refers to fairness of an act situation citizens to nation building, grant benefits and special ◦ QUALITY AND SANCTITY OF LIFE: Quality of life is a privileges and for other purposes” perception based on personal values and beliefs, sanctity REPUBLIC ACT 8425 of life referring to the value of life and the right to live Provides for the institutionalization and enhancement of the ◦ RECIPROCITY: Is a feature of integrity concerned with the social reform agenda by creating the National Anti-Poverty ability to be true to one’s self while respecting and commission (NAPC). supporting the values and views of another. REPUBLIC ACT 344 OR THE ACCESSIBILITY LAW OF 1982 ◦ VERACITY: means truthfulness and refers to telling the Provides for the minimum requirements and standards to truth, or at the least, not misleading or deceiving patients make buildings, facilities, and utilities for public use or their families. accessible to persons with disability, including older persons ISSUES ON CONFLICT OF INTEREST who are confined to wheelchair and those who have difficulty ACTUAL CONFLICT OF INTEREST ISSUES: Between family in walking or climbing stairs, among others. members and caregivers represent the elderly or assist them REPUBLIC ACT 9994. “EXPANDED SENIORS CITIZEN ACT OF in decision-making 2010” ◦ These include conflicts: An act granting additional benefits and privileges to senior ▪ Between spouses and the elder’s wishes and interest citizens, further amending ▪ Between family members and the elder’s wishes and interest Kath Venus 1 1.07 - ETHICO-LEGAL CONSIDERATIONS/ETHICAL PRINCIPLES & MEDICATIONS IN THE CARE OF OLDER ADULTS – NCMB314 REPUBLIC ACT NO. 7432: and otherwise known as “an act to maximize the contribution of senior citizens to nation Number and types of other medications taken building, grant benefits and special privileges and for other Liver (sgpt), Renal Function - creatinine purposes. Presence of comorbidities or other diagnosed diseases REPUBLIC ACT 10155, “THE GENERAL APPROPRIATIONS ACT INAPPROPRIATE MEDICATIONS ADMINISTERED TO ELDERLY OF 2012” Prescriptions for long-acting benzodiazepines, persantine under Section 28 mandates that all government agencies Long-term use of drugs that are to be used for short-term use and instrumentalities should allocate one percent of their only (e.g., histamine blockers, short-acting benzodiazepines, total agency budget to programs and projects for older oral antibiotics) persons and persons with disability Decreased hepatic blood flow results in increased toxicity = REPUBLIC ACT 10645, AN ACT PROVIDING FOR THE Increased SGPT, Increased PT, PTT MANDATORY PHILHEALTH COVERAGE FOR ALL SENIOR Results in increased toxicity when older persons take usual CITIZENS” doses of "first-pass effect" drugs because a smaller portion Amending for the purpose, Republic act No. 7432, as of these drug concentration would be detoxified immediately amended by Republic Act No. 9994 by removing the by the liver qualification that a senior citizen has to be indigent before MEDICATION ERROR being covered by PhilHealth Results from human knowledge based deficiencies and a lack REPUBLIC ACT NO. 10868, “CENTENARIANS ACT OF 2016”, of sophisticated systems to support and monitoring drug AN ACT HONORING AND GRANTING ADDITIONAL BENEFITS therapy. AND PRIVILEGES TO A FILIPINO CENTENARIANS ◦ 2 IMPORTANT DISTINCTIONS IN MEDICATION ERROR All Filipinos who have turned centenarian in the current fiscal LANGUAGE year shall be awarded a plaque of recognition and a cash ▪ ADVERSE DRUG REACTION (ADR) incentive by their respective city or municipal governments in ▫ Any unintended response to a drug that occurs when appropriate ceremonies in addition to the LETTER of drugs are used to diagnose, treat or prevent disease. FELICITATION and centenarian gift of P 100,000.00. ▸ Difficulties in the activity of daily living. PRESIDENTIAL PROCLAMATION NO. 470, SERIES OF 1994 ▸ Cognitive changes declares the first week of OCTOBER of every year as “Elderly ▸ Falls Filipino Week.” ▸ Anorexia, nausea PRESIDENTIAL PROCLAMATION NO. 1048, SERIES OF 1999 ▸ Weight changes declaring a “Nationwide Observance in the Philippines of the ▪ ADVERSE DRUG EVENT (ADE) International Year of Older Persons”. ▫ Any injury that results when medications are used, EXECUTIVE ORDER NO. 105, SERIES OF 2003 and this includes both ADR’s and medication errors Approved and directed the implementation of the program that lead to an ADR. NOTE: the use of too many or wrong types of medications providing for group homes and foster homes for neglected, increases the risk of both an ADE and non-adherence! abandoned, abused, detached, and poor older persons and ▸ FACTORS THAT CONTRIBUTE TO INCREASED RISK persons with disabilities. OF ADE THE PHILIPPINE PLAN OF ACTION FOR SENIOR CITIZENS (2011- ▹ PHARMACOKINETIC CHANGES: What the body 2016) does to the drug? This plan aims to ensure giving priority to community-based DRUG ABSORPTION: Do not usually approaches which are gender-responsive, with effective contribute to drug response and have less leadership and meaningful participation of senior citizens in impact on pharmacokinetics. decision-making processes, both in the context of family and DRUG DISTRIBUTION community. ◦ Altered distribution into the peripheral PHARMACOLOGY AND OLDER ADULTS circulation and tissues ◦ Decrease in plasma albumin levels with Older persons body is at greater risk for adverse drug events age may result in decreased binding of than younger persons drugs that are mainly bound to serum ↓ in body water (as much as 15%) results to increase albumin concentration of water-soluble drugs (e. g. alcohol) ◦ Decrease in total body water, and ↑ in body fat results to more prolonged effects of fat-soluble intracellular water volumes may lead to an drugs increased serum concentration of water ↓ hepatic blood flow results in increased toxicity = Increased soluble drugs such as lithium and alcohol SGPT, increased PT, PTT ◦ Increase in body fat may increase in the ↓ serum albumin level distribution of fat- soluble medications ◦ altered binding capacity (e.g. benzodiazepines) into fatty tissue, ◦ increased serum level of the free or unbound proportion of resulting in prolonged half-lives and drug protein-bound drugs accumulation ◦ toxic level of highly bound drugs HEPATIC METABOLISM PREDICTORS OF MEDICATION RESPONSE ◦ Age-related metabolism is not easily The KIDNEYS excrete most drugs measured. General state of health Kath Venus 2 1.07 - ETHICO-LEGAL CONSIDERATIONS/ETHICAL PRINCIPLES & MEDICATIONS IN THE CARE OF OLDER ADULTS – NCMB314 ◦ Primarily, biotransformation occurs in liver, POLYPHARMACY where enzymatic activity alters and Prescription, administration, or use of more medications that detoxifies the drug to prepare it for are clinically indicated in given patient. excretion. ◦ MULTIPLE MEDICATIONS INCREASE THE CHANCE OF: RENAL EXCRETION ▪ Drug-Drug interaction ◦ The most important pharmacokinetic ▪ ADE’s and ADR’s parameter that changes with age ▪ Error of dosing ◦ Changes is extremely variable, majority of ◦ PREVENTION older adults have a decline kidney ▪ Use of the same pharmacy to fill all prescriptions. function, requiring a decrease dose or ▪ Notification to all prescribing clinicians of drug used. extension of interval for certain drugs ▪ Nurse obtaining a complete history of all drugs used. ◦ SERUM CREATININE may be used as ▫ Prescribed medications indirect estimate of renal function. ▫ Herbal remedies ◦ Creatinine clearance (ml/min) = 140 – Age ▫ OTC medications (in years) x Weight in Kilograms 72 x Serum ▫ Dietary supplements creatinine (mg/dl) ▫ Vitamins ◦ For women, multiply final result by 0.85 ◦ Creatinine: Male: 0.7–1.7 mg/dl; female: OMNIBUS BUDGET RECONCILIATION ACT (OBRA) 0.4–1.4 mg/dl 1. Legislated the appropriate use of medications in ◦ CREATINE CLEARANCE is an estimate of institutionalized older persons GFR and decreases with age. ◦ Use of chemical restraint ◦ BLOOD UREA NITROGEN (BUN): 7-23 ◦ Use of unnecessary drugs mg/dl. Used as the gross measure of Antipsychotic drugs should not be used unless necessary to glomerular function and the production treat a specific condition that is diagnosed and documented and excretion of urea. in the clinical record. ◦ ALKALINE PHOSPHATASE: 34-122 u/l; 2. Beers Criteria Indicator of liver disease. ◦ Commonly used consensus criteria related to ▹ PHARMACODYNAMIC CHANGES: What the drug inappropriate medications. does to the body? ◦ Developed in 1997, and adopted in 1999 by the centers of Aging may result in different responses for medicare and medical services for the regulation of older adults to the same drug concentrations medications in nursing homes at the site of action compared with younger Inappropriate medications administered to older persons adults. include: ◦ CHANGES IN PHARMACODYNAMICS IN ◦ Prescriptions for long-acting benzodiazepines, persantine, OLDER PERSON MAY BE CAUSED BY: propoxyphene ▪ Altered number of receptors or affinity. ◦ Long-term use of drugs that are to be used for short-term ▪ Decreases in receptor binding. use only. (e.g., histamine blockers, short-acting ▪ Altered cellular response to the drug benzodiazepines, oral antibiotics) receptor-receptor interaction. ◦ High doses of drugs prescribed above dosage limitations ▪ Organ pathologic condition. (iron supplements, histamine blockers, antipsychotic ▪ Altered homeostatic mechanism. agents) ▹ DRUG-DRUG INTERACTION An interaction between one drug and another COMMONLY USED MEDICATIONS can result from altered pharmacokinetics or ANXIOLYTICS AND HYPNOTICS pharmacodynamics. Anxiety can be a significant problem in older persons and is It is largely thought that alterations in hepatic often associated with depression & dementia. metabolism are specifically responsible for According to the Beer's list, benzodiazepines with long half- drug-drug interaction. lives should be avoided because of the likelihood of ◦ EX: Warfarin and aspirin: increased risk for accumulation of the patient drug and its active metabolite, bleeding. resulting in increase toxicity ▹ DRUG-FOOD INTERACTION Daily use of both long and short-term acting benzodiazepines The effect of a drug or food can be ◦ Should be limited to less than 4 continuous months influenced by their combined actions. ◦ Should be limited unless an attempt at gradual dose ◦ EX: Theophylline and caffeine: increased reduction is unsuccessful risk for potential toxicity. ◦ Dose reductions should be considered after 4 months ◦ Levodopa and clonidine: decreased anti- ANTIDEPRESSANTS parkinsonian effect. All antidepressants are generally equally effective and ▹ DRUG-DISEASE INTERACTIONS typically take effect in 2 to 4 weeks Certain states may be exacerbated by specific drug therapies, and these drugs may Kath Venus 3 be contraindicated in patients with coexisting underlying disease ◦ EX: Aspirin, NSAID’s and Atrophic gastritis: GI hemorrhage 1.07 - ETHICO-LEGAL CONSIDERATIONS/ETHICAL PRINCIPLES & MEDICATIONS IN THE CARE OF OLDER ADULTS – NCMB314 Overall, tricyclic antidepressants should be avoided in the NONADHERENCE (NON-COMPLIANCE) older patient because of their anticholinergic and sedative side effects profile RISK FACTORS The newer SSRIs are often considered the first choice for Living alone without social support. antidepressants in older adults because of their lack of TCA Visual or auditory impairments. side effects Increasing use of alcohol. ANTIPSYCHOTICS Socioeconomic factors. Should be prescribed only when valid and clear Unpalatable bulk powders or large tablets. documentation of need exists, since many side effects occur NURSING MANAGEMENT with use of these agents. If knowledge deficits are a problem, provide verbal Appropriate indications for antipsychotic prescription include education, reinforced with written instructions and allow time schizophrenia, paranoid states, and symptoms of psychosis for client’s feedback. such as hallucinations and delusions. Encourage a client who “pharmacy shops” to have 3 D's that may justify antipsychotic use: prescriptions filled at the same pharmacy each time. ◦ Danger to the resident or others Provide and assist remembering to take medications. ◦ Distress for the resident Reduce the impact of drug side effects. ◦ Dysfunction of the resident, including interference with ◦ Give adequate intake of fiber and fluid to reduce basic nursing care constipation. Conditions inappropriate Antipsychotic drug use: ◦ Diuretics can be scheduled in the morning to reduce ◦ Wandering interruptions of activities and sleep. ◦ Poor self-care ◦ Use of Isotonic liquids or sugar-free lozenges can help with ◦ Restlessness dry mouth. ◦ Impaired memory ROLE OF THE NURSE ◦ Anxiety Being aware of the routes of eliminations of medications and ◦ Depression the implication of aging on these routes. ◦ Insomnia Being aware of the effects of aging on the typical signs and ◦ Unsociability symptoms of medication toxicity. ◦ Indifference to surroundings Maintaining knowledge of the signs of medication toxicity in ◦ Fidgeting the older adult ◦ Nervousness Drawing random, peak and trough medication levels correctly ◦ Uncooperativeness Knowing when to notify the prescriber of abnormal results. ◦ Agitated behavior when not a danger to self or others. Residents who use antipsychotic drugs should receive ◦ Gradual dose reductions ◦ Drug holidays ◦ Behavioral programming unless clinically contraindicated PRN dose of Neuroleptics ◦ Are not to be used more than twice in a 7-day period without further assessment unless for the purpose of titrating dosage for optimal response unless for management of unexpected behaviors otherwise unmanageable. CARDIOVASCULAR MEDICATIONS The main concerns with the use of cardiovascular medications in older adults are an increased risk of orthostatic hypotension and dehydration, especially with volume-depleting agents and vasodilators. ANTIMICROBIALS Dosing of antibiotics may need to be altered in older clients because of reduced renal elimination. NONPRESCRIPTION AGENTS FDAs division of over-the-counter drug evaluation considers three main criteria when reviewing a request to switch a prescription product to OTC status: ◦ A record of established safety data for the prescription product is necessary ◦ The drug's expected use should be appropriate for OTC treatment ◦ The drug should lack undesirable properties and not require special precautions when used without physician oversight Kath Venus 4