Allocating medical resources: recommendations for a professional response

Ethical decisions in perioperative elder care

Settings involving the extremes of age and illness are the most complex in ethical deliberation and require sound principles that can be clearly applied to individual situations. This article discusses how one's view of the aging process effects clinical decision making. The basic principles of medical ethics (autonomy, beneficence, nonmaleficence, and justice) are discussed along with alternative ethical paradigms that may be more appropriate to the elderly population. Issues such as informed consent, do not resuscitate orders in the operating room, and controversies in end-of-life palliative care specifically impact the role of the anesthesiologist. Anesthesiologists, as medical professionals in a health care team, have a great stake in ethical decision making and the ethics of health care policy.

Mortality one-year postdischarge from a Veterans Affairs geriatric evaluation and management unit: assessing mortality risks

OBJECTIVE

To assess at Geriatric Evaluation and Management Unit (GEM) admission factors that affect mortality 12-months postdischarge and to develop a preliminary risk scoring protocol to guide targeting of GEM care.

SETTING

A 24 bed-GEM at a Veterans Affairs (VA) Medical Center.

DESIGN

Relative risks (RR) were assessed using prospective data; a risk protocol from 1988-1989 data was tested on 1990-1991 patients.

SUBJECTS

A total of 283 male patients, aged 60 to 102, discharged over 4 years.

RESULTS

Age at GEM admission did not correlate with death (r = .14; P = .145), but did correlate with risk scores (r = .33, P < .001). The risk protocol had a sensitivity of .67 and specificity of 1.00. High and low risk patients had mortalities of 51% versus 20%, a Wilcoxon (Gehan) statistic of 15.22, df = 1, and P < .001. Differences in mortality ceased about 100 days postdischarge. Three univariate RR exceeded 1.00 at a 99% Confidence Interval (CI): IADL score (RR: 1.12; CI, 1.03-1.21); nursing acuity score (RR: 1.78; CI: 1.02-3.11); and a primary diagnosis of pneumonia/sepsis (RR: 3.95; CI, 1.60-9.78). Four RRs exceeded 1.00 at a 90% CI: dementia (RR: 1.78; CI, 1.02-3.09); transfer into the GEM from a medical service (RR: 1.47; CI, 1.02-2.12); deconditioning/functional decline (RR: 1.67; CI, 1.12-2.48); and use of a Foley catheter (RR: 2.22; CI, 1.11-4.45). Thirteen other potential risk factors were found in a multivariate analysis.

CONCLUSIONS

The point estimates of risk factors may help clinicians target GEM care, but the development of a useable risk protocol requires additional work. Causal models may be needed to assess patient conditions related to successful treatment in GEMs.