Drugs & Aging

, Volume 19, Issue 5, pp 321–329 | Cite as

Ethical Challenges in End-of-Life Therapies in the Elderly

  • Michael Gordon
Leading Article


With the increasing numbers of elderly in the population of all western countries and the increasing life expectancy at birth, many seniors spend the last period of their life with various afflictions that may require the need for long-term institutional care. During the last period of life, many seniors and their families face decisions that challenge ethical principles and may cause conflict among family members as well as healthcare professionals. The commonly used ethical principles of autonomy, beneficence, nonmaleficence and justice, although forming a useful foundation for the evaluation of decision-making dilemmas, alone cannot resolve many clinically challenging situations. Healthcare professionals must clearly understand the clinical state of the patient for whom a difficult decision is being contemplated. Levels of function, clinical symptoms, the expected trajectory of change and possible treatment options have to be balanced against the person’s values and wishes, either self-expressed directly or through an advance directive, or communicated by surrogate decision makers.

At times, physicians face difficult treatment dilemmas when patients or families request treatments that are not legally sanctioned, such as when physician-assisted suicide is requested by a suffering patient. At other times conflicts occur when patients or surrogates wish to continue with therapies that are no longer considered necessary or suitable by the physician. At the societal level, sometimes an expensive drug that is deemed necessary by the physicians is not covered by a government-sponsored or private health plan. The issue of distributive justice must be considered in a situation such as when long-term facilities or acute hospitals treating frail, cognitively impaired elders consider withholding or withdrawing various treatments because of poor clinical outcomes coupled with excessive costs.

The often controversial issue of nutrition and hydration in the end-of-life period frequently causes treatment conflicts and dilemmas among surrogates and staff, as does the highly charged issue of cardiopulmonary resuscitation in this frail and very vulnerable population. The real challenge for healthcare providers in the field of geriatric long-term care is to balance compassionate and appropriate care with respect for the choices and wishes of patients and their families. This should be accomplished while at the same time safeguarding the professional standards and ethical integrity of healthcare providers responsible for this care.


Amyotrophic Lateral Sclerosis Advance Directive Ethic Education Ethical Challenge Ethic Consultation 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this manuscript. The author has no conflicts of interest that are directly relevant to the content of this manuscript.


  1. 1.
    Gordon M. Challenges of an aging population. Annals of the Royal College of Physicians and Surgeons of Canada 2001; 34: 306–8Google Scholar
  2. 2.
    Gordon M, Singer PA. Decisions and care at the end of life (Last in the geriatric series). Lancet 1995; 346: 163–6PubMedCrossRefGoogle Scholar
  3. 3.
    Baylis FE. Resuscitation of the terminally ill: a response to Buckman and Senn. Can Med Assoc J 1989; 141: 1043–4Google Scholar
  4. 4.
    Buckman R, Senn J. Eligibility for CPR: is every death a cardiac arrest? CMAJ 1989; 140: 1068–9PubMedGoogle Scholar
  5. 5.
    Buckman R, Senn J. Towards a definition of the dying patient: a response to Baylis. Can Med Assoc J 1990; 142: 155–6Google Scholar
  6. 6.
    Ahronheim JC, Morrison RS, Baskin SA, et al. Treatment of the dying in the acute care hospital. Advanced dementia and metastatic cancer. Arch Intern Med 1996; 156: 2094–100PubMedCrossRefGoogle Scholar
  7. 7.
    Gordon M. Should we provide cardiopulmonary resuscitation to elderly patients in long-term care? Cardiol Elderly 1995; 3: 53–7Google Scholar
  8. 8.
    Ebell MH, Becker LA, Barry HC, et al. Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis. J Gen Intern Med 1998; 13: 805–16PubMedCrossRefGoogle Scholar
  9. 9.
    CMA Policy Summary: joint statement on resuscitative interventions. CMAJ 1994; 151: 1176A–CGoogle Scholar
  10. 10.
    Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 4th Ed. New York: Oxford University Press, 1994Google Scholar
  11. 11.
    Beauchamp T. The ‘Four Principles Approach’ In: Gillon R, editor. Principles of health care ethics. New York (NY): John Wiley and Sons, 1994: 3–12Google Scholar
  12. 12.
    Markwell HJ, Brown BF. Bioethics for clinicians: 27. Catholic bioethics. CMAJ 2001; 165: 189–92PubMedCrossRefGoogle Scholar
  13. 13.
    Daar AS, Al Khitany AB. Bioethics for clinicians: 21 Islamic bioethics. CMAJ 2001; 164: 60–3PubMedGoogle Scholar
  14. 14.
    Goldsand G, Rosenberg ZRS, Gordon M. Bioethics for clinicians 22. Jewish bioethics. CMAJ 2001; 164: 219–22PubMedGoogle Scholar
  15. 15.
    Daly BJ. Special challenges of withholding artificial nutrition and hydration. J Gerontol Nurs 2000; 26(9): 25–31PubMedGoogle Scholar
  16. 16.
    Hoefler JM. Making decisions about tube feeding for severely demented patients at the end of life: clinical, legal and ethical considerations. Death Stud 2000; 24: 233–54PubMedCrossRefGoogle Scholar
  17. 17.
    Mitchell SL, Kiely DK, Lipsitz LA. The risk factors and impact on survival of feeding tube placement in nursing home residents with severe cognitive impairment. Arch Intern Med 1997 Feb; 157: 327–32PubMedCrossRefGoogle Scholar
  18. 18.
    Gillick MR. Rethinking the role of tube feeding in patients with advanced dementia. N Engl J Med 2000 Jan; 342: 206–10PubMedCrossRefGoogle Scholar
  19. 19.
    Goodhall L. Tube feeding dilemmas: Can artificial nutrition and hydration be legally or ethically withheld or withdrawn? J Adv Nurs 1997; 25: 217–22PubMedCrossRefGoogle Scholar
  20. 20.
    Hare J, Pratt C, Nelson C. Agreement between patients and their self-selected surrogates on difficult medical decisions. Arch Intern Med 1992; 152(5): 1049–54PubMedCrossRefGoogle Scholar
  21. 21.
    Rockwood K, Hogan DB, MacKnight C. Conceptualisation and measurement of frailty in elderly people. Drugs Aging 2000 Oct; 17(4): 295–302PubMedCrossRefGoogle Scholar
  22. 22.
    Miles SH, Meyers R. Untying the elderly. 1989 to 1993 update. Clin Geriatr Med 1994 Aug; 10(3): 513–25PubMedGoogle Scholar
  23. 23.
    Dawkins VH. Restraints and the elderly with mental illness: ethical issues and moral reasoning. J Psychosoc Nurs Ment Health Serv 1998; 36: 22–7PubMedGoogle Scholar
  24. 24.
    Meisel A, Snyder L, Quill T. Seven legal barriers to end-of-life care. JAMA 2000; 284: 2495–501PubMedCrossRefGoogle Scholar
  25. 25.
    Sue Rodriguez and the Right to Die [online]. Available from URL: [Accessed 2002 Apr 30]
  26. 26.
    NORML — The National Organization for the Reform of Marijuana Laws [online]. Available from URL: [Accessed 2002 Apr 30]
  27. 27.
    Willems DL, Daniels ER, van der Wal G, et al. Attitudes and practices concerning the end of life: a comparison between physicians from the United States and from the Netherlands. Arch Intern Med 2000; 160: 63–8PubMedCrossRefGoogle Scholar
  28. 28.
    Morgentaler H, Smoling LF, Scott R. Appellants v. Her Majesty The Queen Respondent and The Attorney General of Canada Intervener: Indexed as: R. v. Morgentaler [online]. Available from URL: [Accessed 2002 Apr 30]
  29. 29.
    Morgentaler H. An interview with Dr. Henry Morgentaler [by Rick L Hengel]. CMAJ 1985; 133: 490–5PubMedGoogle Scholar
  30. 30.
    The Kevorkian Verdict -The life and legacy of the suicide doctor — air date: May 14, 1996: [online]. Available from URL: [Accessed 2002 Apr 30]
  31. 31.
    Roscoe LA, Malphurs JE, Dragovic LJ, et al. A comparison of characteristics of Kevorkian euthanasia cases and physician-assisted suicides in Oregon. Gerontologist 2001; 41: 439–46PubMedCrossRefGoogle Scholar
  32. 32.
    The Kevorkian Controversy — Detroit Free Press [online]. Available from URL: [Accessed 2002 Apr 30]
  33. 33.
    Leland J. Advance directives and establishing the goals of care. Prim Care. 2001; 28: 349–63PubMedCrossRefGoogle Scholar
  34. 34.
    Molloy DW, Guyatt GH, Russo R, et al. Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial. JAMA 2000; 283: 1437–44PubMedCrossRefGoogle Scholar
  35. 35.
    Treloar AJ. Advance directives: limitations upon their applicability in elderly care. Int J Geriatr Psychiatry 1999; 14: 1039–43PubMedCrossRefGoogle Scholar
  36. 36.
    Marcus EL, Clarfield AM, Moses AE. Ethical issues relating to the use of antimicrobial therapy in older adults. Clin Infect Dis 2001; 33: 1697–705PubMedCrossRefGoogle Scholar
  37. 37.
    Fabiszewski KJ, Volicer B, Volicer L. Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients. JAMA 1990; 263: 3168–72PubMedCrossRefGoogle Scholar
  38. 38.
    Pereira J, Watanabe S, Wolch G. A retrospective review of the frequency of infections and patterns of antibiotic utilization on a palliative care unit. J Pain Symptom Manage 1998; 16: 374–81PubMedCrossRefGoogle Scholar
  39. 39.
    Gordon M, Turner L, Bourret E. Addressing ethical issues in geriatrics and long-term care: ethics education at the Baycrest Centre for Geriatric Care. Med Law 2000; 19(3): 475–91PubMedGoogle Scholar
  40. 40.
    Gordon M. The birthday present: A physician puts his own family on hold to help another come to a troubling decision. Medical Post Sept. 4, 2001 [online]. Available from URL: [Accessed 2002 Apr 30]
  41. 41.
    Pellegrino ED. Nonabandonment: An old obligation revisited. Ann Intern Med 1995; 122: 377–8PubMedGoogle Scholar
  42. 42.
    Quill TE, Cassel CK. Nonabandonment: A central obligation for physicians. Ann Intern Med; 122: 368–74Google Scholar
  43. 43.
    Crawshaw R, Rogers DE, Pellegrino ED, et al. Patient-physician covenant. JAMA 1995; 273: 1553PubMedCrossRefGoogle Scholar
  44. 44.
    Peile E. Supporting primary care with ethics advice and education. BMJ 2001; 323: 3–4PubMedCrossRefGoogle Scholar
  45. 45.
    Tweeddale MG. Teaching old dogs new tricks—a personal perspective on a decade of efforts by a clinical ethics committee to promote awareness of medical ethics. J Med Ethics 2001; Suppl. 1: i41–3Google Scholar
  46. 46.
    DuVal G, Sartorius L, Clarridge B, et al. What triggers requests for ethics consultations? J Med Ethics 2001; Suppl. 1: i24–9Google Scholar
  47. 47.
    Slowther A, Bunch C, Woolnough B, et al. Clinical ethics support services in the UK: an investigation of the current provision of ethics support to health professionals in the UK. J Med Ethics 2001 Apr; 27Suppl. 1: i2–8PubMedCrossRefGoogle Scholar
  48. 48.
    Slowther A, Hope T, Ashcroft R. Clinical ethics committees: a worldwide development. J Med Ethics 2001; Suppl. 1: ilGoogle Scholar
  49. 49.
    Aulisio MP. Ethics consultation: is it enough to mean well? HEC Forum 1999; 11: 208–17PubMedCrossRefGoogle Scholar
  50. 50.
    Kuczewski MG. When your healthcare ethics committee ‘fails to thrive’. HEC Forum 1999; 11: 197–207PubMedCrossRefGoogle Scholar
  51. 51.
    Engelhardt Jr HT. Healthcare ethics committees: re-examining their social and moral functions. HEC Forum 1999 Jun; 11(2): 87–100PubMedCrossRefGoogle Scholar
  52. 52.
    McKneally MF, Singer PA. Bioethics for clinicians: 25. Teaching bioethics in the clinical setting. CMAJ 2001; 164: 1163–7PubMedGoogle Scholar
  53. 53.
    Singer PA, MacDonald N. Bioethics for clinicians: 15. Quality end-of-life care. CMAJ 1998; 159: 159–62PubMedGoogle Scholar
  54. 54.
    Gordon M. Whose life is it and who decides?: a dilemma in long-term care. Annals of Long-term Care. In pressGoogle Scholar
  55. 55.
    Nenner F. Listen to the voices [letter]. BMJ 2001; 322: 372PubMedCrossRefGoogle Scholar
  56. 56.
    Charon R, Montello M. Framing the case: narrative approaches for healthcare ethics committees. HEC Forum 1999; 11: 6–15PubMedCrossRefGoogle Scholar
  57. 57.
    Bioethics for clinicians [online]. Available from URL: [Accessed 2002 Apr 30]

Copyright information

© Adis International Limited 2002

Authors and Affiliations

  • Michael Gordon
    • 1
  1. 1.Geriatrics and Internal Medicine, Baycrest Centre for Geriatric CareUniversity of TorontoTorontoCanada

Personalised recommendations