Elderly Patients and Informed Consent
By Jeremy Wale
First, some history on informed consent. It began in earnest as a legal requirement with a New York lawsuit back in the early 1900s. Justice Cardozo of the New York Court of Appeals stated, “[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body…”1 This Appeals Court decision laid the framework for our modern-day informed consent laws and rules.
Over the years, case law relating to informed consent has evolved—with some states introducing statutes governing consent requirements for healthcare providers.
Informed consent laws differ by state in the amount of information a healthcare provider is required to disclose to the patient. Some states employ a “reasonable physician” standard, meaning a healthcare provider must provide the amount of information a reasonably prudent physician would provide in the same or similar circumstances.2 Other states use a “reasonable patient” standard, requiring that a physician provide information that a reasonable patient would need to make an informed decision.3
Generally speaking, physicians do well to provide patients with enough information to be able to make a fully informed decision about medical care. Exceptions to the informed consent requirement can be made for emergencies where the patient is unconscious and arrives at a facility needing a life-saving procedure. Be sure to check state laws so you know what is required for your informed consent discussions with patients.
Illnesses that require recurring treatments present unique challenges for physicians obtaining informed consent. Elderly patients are more likely to require recurring treatments such as dialysis, radiation, and chemotherapy. When a patient agrees to undergo these types of treatment, the initial informed consent process ideally covers the entire course of treatment. Patients are told they may question the treatment process, as well as each individual treatment. Informed consent may require more than one conversation, especially in the case of chemotherapy, radiation, or dialysis.
Consider having an in-depth, detailed informed consent discussion with each patient before you begin recurring treatments. Have the patient sign an informed consent document acknowledging that discussion and the patient’s consent to the course of treatment. Verifying with the patient at each visit that he or she wishes to continue the course of treatment is a good idea—as is noting that verification in the medical record.
Issues Associated with Aging
Elderly patients also are more likely to present you with consent issues related to powers of attorney (POA), guardianships, mental competence, etc. Who, if not the patient, do you need to obtain consent from for an elderly patient’s medical care?
Powers of attorney come in various forms; limited, general, durable, and healthcare are the most common. A POA is a document where a “principal” names an attorney-in-fact (“agent”) to act on his or her behalf. The POA will usually outline the breadth of the agent’s decision-making authority. Depending on how it is drafted and the type of POA, the agent may have very limited or virtually unlimited authority to make decisions on behalf of the principal.
The type of POA provided to your practice will have a large impact on whether the individual named in the POA has the authority to make healthcare decisions on behalf of the patient. A healthcare POA is the most straight-forward type of POA. This document specifically outlines healthcare decision-making authority granted to the agent by the principal. We encourage you to read healthcare POAs carefully to determine the authority granted to the agent.
Non-healthcare POAs typically do not give the agent the authority to make healthcare decisions. Exceptions exist. Outside of a healthcare POA, if healthcare decision-making authority is not specifically granted within a POA, do not make presumptions.
You also may encounter patients who lack the mental capacity to continue to make healthcare decisions. Patients with dementia or Alzheimer’s present consent issues you should be ready to address. You may be confronted with family disputes, court orders, conflicting POAs, or other documents that cloud the consent issue for a mentally incapacitated patient.
One of the best ways to avoid the confusion of consent for an elderly patient is to establish consent when the patient is of sound mind. Ask your elderly patients if they have executed any type of POA, living will, or other document outlining who has decision-making authority in the event they become incapacitated or otherwise unable to make decisions. Request a copy of documentation outlining decision-making authority for your patients. Maintain this documentation in the medical record. And consider reviewing this with the patient periodically to ensure it is still current.
Consent can be a difficult topic to discuss. If you have any questions, please call your healthcare professional liability insurer.
Jeremy Wale, JD, is a Risk Resource Advisor with ProAssurance Group
1 Schloendorff v. Society of New York Hospital, 211 N.Y. 125, 129 (1914).
2 Thaw v. North Shore Univ. Hosp., 129 A.D.3d 937, 939 (2015).
3 Janusauskas v. Fichman, 264 Conn. 796, 810 (2003).