Ethics in Geriatric Medicine
A CASE-BASED WORKSHOP
During the second week of the Geriatrics rotation, all students will meet together one morning to discuss cases of patients seen and situations experienced during the rotation, with emphasis on the ethical dimensions of geriatric and palliative care practice and care. This workshop will be conducted much like "ethics rounds," with students presenting cases of interest that are challenging, troubling, meaningful, and so on. Faculty members of the Center for Biomedical Ethics and Humanities will lead discussion of the cases brought by students to explore ethical, legal and social matters related to the clinical practice of geriatrics and palliative care, including the patient's experience of illness; the doctor's reactions/responses and role in providing care; the challenges and opportunities presented by today's complex healthcare system; and the relationship between the patient and physician as well as relationships with families, staff, and colleagues. We will pay particular attention to ethical dilemmas that arise in the care of the elderly or dying patient, but many other concerns are also appropriate for this discussion.
Prior to the workshop, as a student, you need to
1) Review "Ethical Issues in Geriatrics: A Guide for Clinicians" Mayo Clin Proc 2004;79:554-562. Ethics Article
2) Observe cases and situations during your clinical experiences and consider these for the presence of ethical concerns or dilemmas. Sometimes ethical issues are obvious, as when someone refuses treatment, but issues may also be more subtle, as when a patient's decisionmaking capability seems to waver or when questions arise around maintaining or breaching confidentiality. What issues occur commonly for and in the care of elderly persons? How does paying attention and identifying/addressing these problems improve care?
3) Take note of how cases and clinical situations arouse reactions/responses in you. For instance, emotions move physicians toward some patients (as when physicians like/identify with a patient for some particular reason) or away from other patients (as when a patient is angry, uncooperative, or dissatisfied). What do you notice when you examine your own interactions with patients? Are there any reactions you habitually have? In what kinds of situations and with what sorts of patients do they occur? What is the impact of your reactions on patient care? On your own experience of doctoring?
Come to the workshop prepared to present at least one case involving an ethical situation. Our workshop discussions will be based in part on cases and situations brought and presented by students. You may want to keep written notes or a journal of your experiences throughout the rotation, so that, at the workshop, you can either read the story you have written about your experience or speak about cases from your notes.
NARRATIVE ASSIGNMENT: This assignment is offered to help students understand the geriatric patient as a person and to realize that all geriatric patients have meaningful life stories.
During the clerkship, each student will write a 1-3 page type written patient-centered narrative. The narrative will be developed based on an interaction with a patient during the clerkship, and it can be written from any point of view that the student chooses. The narrative should also contain some personal reflections by the student regarding the impact of the exercise, eg, What insights did the student gain? How did the exercise influence the student's understanding of medical practice? What surprised the students? The student can select a patient solely for the purpose of this assignment, informing the patient of the task. Or the student can obtain an expanded history from a patient being assessed during an HPI, other exam, or a follow-up visit.
Examples of how to do this assignment:
1) Think of life events that the patient may have experienced, eg, living through World War II or the Great Depression. Ask the patient to tell you about the experience of that time.
2) Ask the patient to select one of the most meaningful life experiences and to tell you about it.
3) Ask the patient to tell you what they've learned about life or aging. What lessons would he/she like to share with you?
4) Ask the patient to tell you about a difficult time and how they made it through that period in their life.
5) Ask the patient to tell you about childhood, career, family, etc.
6) There are many options, so the student can engage the patient in anyway that seems appropriate, eg, embed the conversation within an established relationship with the patient; tell the patient about the assignment and ask for help.
The student is required to email a copy of this assignment to each of the following by the final day of the clerkship:
Lois Shepherd at firstname.lastname@example.org
Marcia Childress at email@example.com
Huai Cheng at firstname.lastname@example.org
Students are also encouraged to provide a copy to the primary preceptor. The papers will be read by some of the faculty members of the Center of Bioethics and Humanities: Drs. Morhmann, Davis, Shepherd, Chen, Childress.