NCM 114 LEC PHARMACODYNAMICS
ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF • Time course and effect of drugs on cellular and organ
OLDER ADULT function
• What drugs do once they’re in the body.
LAWS AFFECTING SENIOR CITIZENS/ OLDER PERSONS • Effects of similar drug concentrations at site of action
RA 7432 may be greater or less than those in younger patients.
• Act to maximize contribution of senior citizens to Potential for increased sensitivity to medications at
nation building, grant benefits and special privileges cellular level must be considered when administering
and for other Purposes. to elderly patient.
• April 23, 1992: Corazon Aquino
Adverse Drug Reactions
Ra 9257 or Expanded Senior Citizens Act Of 2003 • WHO: Any noxious, unintended, and undesired effect
• Act Granting Additional Benefits and Privileges to of a drug, which occurs at doses used in humans for
Senior Citizens Amending for Purpose Republic Act prophylaxis, diagnosis, or therapy.
No. 7432. • Two different types of ADRs:
• February 26, 2004: Gloria Macapagal- Arroyo ➢ Drug-drug interactions: alteration of
pharmacokinetics or pharmacodynamics of drug
RA 9994 or Expanded Senior Citizens Act Of 2010 A when taken at same time as drug B.
• Act Granting Additional Benefits and Privileges to ➢ Drug disease interactions: worsening of disease
Senior Citizens, Further Amending Republic Act No. by medication.
7432.
• February 15, 2010: Gloria Macapagal- Arroyo. FOOD-DRUG INTERACTIONS
➢ 20% discount and exemption from value added • Presence or absence of food may reduce or increase
tax (VAT) bioavailability of a medication, leading to
➢ 5% discount in utilities provided that utility is unanticipated effects.
named to senior citizen and will not exceed
100kwh/month and 30m Polypharmacy
• Many older patients are prescribed multiple drugs,
MEDICATIONS OF OLDER ADULTS take over-the-counter medications and often
• Normal aging is associated with certain physiological prescribed additional drugs to treat side effects of
changes that influence drug response. medications that they are already taking.
• Both pharmacokinetics and pharmacodynamics play a • ↑ number of medications leads to polypharmacy:
role in how a person will respond to drug. prescription, administration, or use of more
medications than clinically indicated in given patient.
PHARMACOKINETICS
• Time course by which body absorbs, distributes, Compliance
metabolizes, and excretes drugs. • Although age alone does not affect compliance, 40%
• How drugs move through body and how quickly it elderly people do not adhere to their medication
occurs. regimen.
• The more complex the medication regimen, the less
Absorption likely the patient will comply.
• Movement of a drug from site of administration, • Nonadherence may result from patient trying to avoid
across biological barriers, into plasma. side effects and reducing amount of drug consumed,
• Rate of drug movement through body may decrease lack of money, or forgetfulness.
with age, the extent of drug absorption is least
affected by age. MAJOR ETHICAL PRINCIPLES
• Certain disease and simultaneous use of several Goal of Ethical Care
medications have been shown to decrease absorption • Voiding or minimizing harms and maximizing benefits.
of some medications. Concern and focus should be on preserving and
respecting personhood. Is done through recognition
Distribution of wants, collaboration, play, validating, facilitation,
• Movement of a drug from plasma into cells. As and giving.
patients age, total body water declines and fat stores • Ethics must recognize and deal with competition
increase. between organizational/ community interests vs.
• Physiological change affects distribution phase of individual interests.
highly water-soluble and fat-soluble drugs.
• With age, hepatic mass and blood flow decrease Autonomy
(hepatic metabolism of medications is reduced). • One’s right to control one’s destiny, that is, to exert
• With age, renal mass and blood flow are reduced one’s will.
(decrease amount of drug that goes through renal • Principal issue revolves around whether older adult
excretion). can assess situation and make a rational decision
independently.
Beneficence Adult day • Provide meals, recreation, health-related
• Duty to do good for others, and specifically to avoid care or adult services (e.g., medication management;
day health weight, blood pressure, and diabetes
harm in the process. centers monitoring), transportation, assistance with
• Nonmaleficence ADLs, and exercise in a group environment
• Involves doing no harm and avoiding negligence that for individuals with cognitive and/or
leads to harm. functional impairments.
• Physician involvement: minimal (often
initial medical summary required).
Justice Program of • Provides comprehensive long-term services
• Focuses of fairness in treatment of others, non- All-Inclusive and supports to individuals age 55 or older,
discrimination and duty to treat individuals fairly; Care for the are eligible for nursing home care and can
Elderly (PACE) live safely in the community.
based on irrelevant characteristics.
• Care coordinated by interdisciplinary team.
• Duty to distribute resources fairly, non-arbitrarily, and • Physician involvement: variable according
non-capriciously. to needs of participant but physician is
often on site and may visit people in homes.
Fidelity Specialized • Provides specialized care for people with
dementia dementia—often a separate secured unit,
• Duty to keep promises.
units trained staffing, special programming,
modified physical environment, and family
CARE FACILITIES involvement.
Type Definition and Description • Physician involvement: variable
Short-Term (Post-Acute) Settings Home care/ • Home health aide or homemaker or
Inpatient • Provide intensive rehabilitation using personal care companion that provides nonmedical care
Rehabilitation rehabilitation interdisciplinary team (help with ADLs, cooking, shopping,
facilities approach in facility’s inpatient hospital laundry) to enable older adults with chronic
environment. illnesses to remain at home.
• Patients must receive multiple therapy • Physician involvement: minimal.
disciplines at least 15 hours per week and Hospice • Individual certified as having life expectancy
make measurable improvement of 6 months or less. Focus on comfort and
• Physician involvement: high (2-3 visits per quality of life rather than curative
week). treatments.
Skilled • Provide services essential to maintenance • Physician involvement: variable depending
nursing or restoration of health. on acuity and setting (hospice medical
facilities • Admission requires 3-night hospital stay director and primary care physician often
within last 30 days. share some responsibility).
• Physician involvement: moderate (required HOSPICE CARE
visit every 30 days, but often more frequent Provides one option for non-life-prolonging care and
as medically necessary).
Chronic care • Care for patients with hospitals complex
has philosophy:
hospitals care needs (ventilator and weaning) • Provides care and support for people in last phases of
discharged from hospitals. incurable disease so they may live as fully and
• Physician involvement: high (on-site comfortably as possible.
availability daily).
• Recognizes dying as part of normal process of living
Home health • Care for patients who are care confined to
care home and require intermittent skilled and focuses on maintaining quality of remaining life.
nursing care. • Affirms life and neither hastens nor postpones death.
• Physician involvement: low (as medically • Exists in hope and belief that through appropriate
necessary when identified by the home care and promotion of a caring community sensitive
health care team).
to their needs, patients and their families may be free
Outpatient • Care for patients who can travel to
Rehabilitation rehabilitation location. to attain degree of mental and spiritual preparation
programs • Physician involvement: minimal (as for death that is satisfactory to them.
problems are identified by rehabilitation • Provide comfort and dignity at end-of-life eligibility
specialist). for hospice services is based on life expectancy of 6
Long-Term Settings
months or less, if an illness runs its normal course.
Nursing • Provide room, meals, personal care, 24-
homes hour nursing care, medication • Services are available as long as a patient is
management, social and recreational considered to be terminally ill, even though it may be
activities, and medical care to residents longer than 6 months.
with chronic conditions.
• Utilize team to address physical, emotional, social,
• Physician involvement: moderate (required
visit every 60 days and as medically and spiritual needs of patient and family.
necessary).
Residential • Regulated under a variety of assisted living PALLIATIVE CARE
care/ assisted names (including personal care homes, • Evolved from hospice movement in 1960s and 1970s.
living group communities’ homes, board and care
communities
It became more mainstream as nurses and physicians
homes, and others).
• Provide room, meals, supervision, embrace its philosophy of whole-person care for
assistance with medications, some personal people with life-limiting illnesses who are not yet
care. eligible for hospice support
• May charge base rate with added fees for • Comprehensive management of the physical,
additional services.
• Physician involvement: low (required
psychological, social, spiritual; and existential needs
yearly and as medically necessary). of patients suited to care of people with incurable
progressive illnesses.
• Area of special expertise within medicine, nursing, END-OF-LIFE CARE
social work, pharmacy, chaplaincy, and other 8 themes were identified to form core characteristics of
disciplines. (1997 taskforce) end-of-life caregiving: Phillips and Reed (2009)
1. Unpredictable. Each crisis could be last or just next in
Goal a series of crises.
• To achieve best possible quality of life for patients 2. Intense, constant, and engulfing. Feeling of
and their families. overwhelming responsibility exists and cannot be
• Control of pain, of other symptoms, and of shared.
psychological, social, and spiritual problems is 3. Complex. Treatment regimens must be balanced
paramount with complex interpersonal relationships with
patient and other family members.
Bill of Rights for Long-Term Care Residents 4. Frightening. Situations such as falls, bleeding,
1. Right to voice grievances and have them remedied behavior problems, or medication reactions frighten
2. Right to information about health conditions and many caregivers.
treatments and to participate in one's own care to 5. Anguishing. Watching the suffering of beloved family
the extent possible member causes many caregivers sever angst.
3. Right to choose one's health care providers and 6. Profoundly moving. Many precious moments have
speak privately with one's health care providers spiritual or sacred overtones.
4. Right to consent to or refuse all aspects of care and 7. Affirming. Bonding with older patient is moving
treatments experience.
5. Right to manage one's own finances if capable, or to 8. Involves dissolving familiar social boundaries.
choose one's own financial advisor Caregivers and older adults share intimacies such as
6. Right to be transferred or discharged only for toileting, changing diapers, or catheter care, which
appropriate reasons would otherwise not be shared.
7. Right to be free from all forms of abuse
8. Right to be free from all forms of restraint to the Common End-of-Life Documents
extent compatible with safety Type of Definition Signature
document
9. Right to privacy and confidentiality concerning one's
Do not Executed by competent person Physician,
person, personal information, and medical resuscitate indicating that if heartbeat and nurse,
information order breathing cease, no attempts to practitioner,
10. Right to be treated with dignity, consideration, and restore them should be made or patient
respect in keeping with one's individuality Health Designates surrogate decision Patient or
Care Proxy maker for health care matters witnesses
11. Right to immediate visitation and access at any time or that takes effect on one’s
for family, health care providers, and legal advisors; Medical incompetency. Decisions must
the right to reasonable visitation and access for Power of be made following person’s
others Attorney relevant instructions or in his or
her best interests
Living will Directs those extraordinary Patient or
Contemporary Long-Term Care Nursing Facility measures are not used to witnesses
• Offer continuing care for chronically ill, disabled, and artificially prolong life if
medically frail persons, with a goal, promoting highest recovery cannot reasonably be
quality of life possible for all residents. expected. Measures may be
specified.
• Ouslander and Weinberg (2003) formulated medical Advanced Explains person’s wishes about Patient or
goals for Care in the long-term care setting. Many of Health treatment in case of witnesses
these goals are common to all members of the health Directive incompetency or inability to
care team; others that represent unique contributions communicate. Often used in
conjunction with Health
of nursing have been added:
Care Proxy or Medical Power of
1. Provide a safe and pleasing environment that Attorney.
supports engagement and independence.
2. Ensure that basic physiological, psychological, social, Origin of Advance Directives
and spiritual needs are met. Patient Self-Determination Act (1991)
3. Maintain or improve function. • Purpose of law: to ensure rights of individuals "to
4. Maximize the quality of life. accept or refuse medical or surgical treatment"
5. Manage symptoms of acute and chronic conditions • Healthcare institutions: inform individuals about right
to prevent complications and promote health. to participate in decisions about their healthcare and
6. Prevent suffering and treat discomfort. right to make advance directives
7. Prevent excess disability.
8. Preserve dignity. Purposes of Advance Directives
9. Encourage autonomy. • Written instructions to healthcare provider before the
10. Support the family unit. need for medical treatment
11. Provide compassionate end-of-life care.
• Guidance to healthcare professionals how to proceed
• Provides immunity for healthcare staff
Types of Advance Directives 6. Fraud: deceit with intention to illegally or unethically
• Living Will: care wanted under certain circumstances gain at expense of another
(CPR) 7. Invasion of Privacy: personal life; private part
• Durable Power of Attorney for Health Care: 8. Larceny: crime involving unlawful taking or theft of
designated healthcare proxy personal property of another person
• The Five Wishes: Aging with Dignity advance directive 9. Negligence: act that results injury
program ➢ Malfeasance: bribe
• POLST: physician orders that specify treatment ➢ Misfeasance: performing legal act but doing so
decisions in a way that causes harm (duty shortcut)
Five Wishes ➢ Nonfeasance: failure to perform act required by
Discuss values and treatment goals law
1. The person I want to make decisions if I cannot ➢ Malpractice: breach duty of care by medical
2. The kind of medical treatment I want or don't want provider or medical facility
3. How comfortable I want to be ➢ Criminal negligence: medical provider makes a
4. How I want people to treat me mistake in treating patient and results in harm
5. What I want my loved ones to know to patient that is punishable by law
POLST (POLST or MOLST) Measures to Help Nurses make Ethical Decisions
Physicians' Orders for Life Sustaining Treatment • Although guidelines exist, no solid answers can solve
• Began in Oregon in 1991, now a national movement all ethical dilemmas that nurses face. Nurses should,
• Not a living will; rather MD order for treatment however, minimize struggles in making ethical
preferences decisions by using critical thinking and employing
• Transportable following measures:
• POLST form decreases unwanted treatment and 1. Encourage patients’ expressions of desires
enhances symptom management 2. Identify significant others who impact and are
impacted
Who can make decisions if older adult isn't capable? 3. Know thyself
Washington State: listed in the order of priority 4. Read
• Appointed guardian or Durable Power of Attorney 5. Discuss
(DPOA) 6. Form an ethics committee
• Spouse 7. Consult
8. Share
• Adult (18+ years) children
9. Evaluate decisions
• Older adult's parents (if still living & capable)
• Adult brothers and sisters
• If none of the above, guardian may be appointed
SPIRITUALITY AMONG OLDER PERSONS
• Supporting Spiritual Needs
• Strong spiritual beliefs facilitate health and healing;
therefore, it is therapeutically beneficial to support
patients’ spirituality and assist them in fulfilling
spiritual needs.
• Nursing interventions use to assist patients:
1. Identifying needs
2. Being available
3. Honoring beliefs and practices
4. Providing opportunities for solitude
5. Promoting hope
6. Assisting in discovering meaning in challenging
situations
7. Arranging for religious needs to be met
8. Praying with and for
ETHICAL DILEMMAS
• Acts that could result in Legal Liability for Nurses
1. Assault: imminent threat
2. Battery: no consent touching
3. Defamation of Character
➢ Slander: verbal
➢ Liber: written/published
4. Defamation: damaging one’s reputation
5. False Imprisonment: illegal detention
