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The decision to seek nursing home placement will be faced with increasing frequency as the population over age 65 continues to grow. Although this is a difficult juncture under any circumstances, the ethical issues accompanying such a move for persons of diminished competence are unusually complex and require involvement of many concerned parties. In a typical case presentation, the social context informing these decisions is described, including bias against the aged, perceptions of scarce resources in health care, and the problematic role of the courts. The perspectives and moral obligations of the patient, family, and health professionals are discussed and contrasted to clarify the sometimes conflicting roles and needs of those three parties. A stepwise process of decision making before nursing home placement is offered in an effort to choose the least restrictive alternative for the patient while respecting the needs of concerned persons.

Chronic dementia syndromes are often assumed to be untreatable, and thus patients with these disorders are neglected and their condition worsens. Many interventions, however, can improve the functional capacity of these persons, and thus their abandonment has no ethical justification. Analysis of this problem points to psychological, educational, and institutional barriers responsible for the inadequate care of the demented. Physicians have the ability and power, and therefore the responsibility, to improve this situation.

Medical ethics education is instruction that endeavors to teach the examination of the role of values in the doctor's relationship with patients, colleagues, and society. It is one front of a broad curricular effort to develop physicians' values, social perspectives, and interpersonal skills for the practice of medicine. The authors define medical ethics education as more clinically centered than human values education and more inclusive of philosophical, social, and legal issues than is interpersonal skills training. The authors review the history of the emergence of medical ethics education over the last 20 years, examine the areas of consensus that have emerged concerning the general objectives and premises for designing medical ethics programs, and describe teaching objectives and methods, course content, and program evaluation used in such programs on both preclinical and clinical levels. The four interrelated requirements for successful institutionalization of medical ethics education programs are defined and discussed, and the paper ends with an overview of the uncertain future of medical ethics education, an accepted but still not fully mature part of physician training in the United States. An extensive reference list accompanies the article.

The technology of modern weapons, especially nuclear weapons, poses a critical threat to the health of all people. In addition to the unprecedented risk of massive destruction to living things and to the ecosphere, the resources used in production of these arsenals cause an economic threat to the health of populations even if the weapons are never used. Medical and social scientists have a responsibility to work for the prevention of nuclear war and the reversal of the arms race. This may imply an obligation to work towards the prevention of war in general. Professional responsibility in this regard is based on (1) special expertise, (2) influence in society and (3) the symbolic power of the values of life, health and human dignity.

We studied attitudes of health professionals toward life-sustaining treatment. A patient management questionnaire sent to staff physicians and nurses in 183 Oregon nursing homes consisted of eight patient sketches which varied age, mental status, and enjoyment of life. Respondents were asked whether they would favor tube-feeding to correct malnutrition in each case. Nurses showed higher preferences for tube-feeding than did physicians (P = .05). For both professions, patient happiness was the strongest and most significant (P less than .0001) influence upon preferences for tube-feeding. Both professions also showed a significant (P less than .001) tendency to give younger patients higher preferences for tube-feeding. Physicians showed a significant (P less than .001) influence of patient mental status upon preferences, while patient mental status did not affect nurses' preferences. Identifiable clinical factors appear to influence attitudes of physicians and nurses toward tube-feeding decisions.

Plasmapheresis combined with prednisone and azathioprine therapy produced striking clinical improvement in five patients with myasthenia gravis who still had moderate to severe disability despite thymectomy, high-dose prednisone therapy and optimal doses of cholinesterase inhibitors. Serial determinations of titers of serum antibody toward the acetylcholine receptor demonstrated a fall to 21 +/- 5 per cent (mean +/- S.D.) of the original levels concurrently with the patients' increasing strength. Clinically improved patients maintained lowered titers, whereas clinical relapses were associated with a rebound in titer. Our results suggest that plasmapheresis will find a place in the management of patients with myasthenia gravis, and they implicate antibodies to acetylcholine receptor as a pathogenic factor in this disease.

Doctors are increasingly faced with the ethical dilemma of making end-of-life medical care decisions for older patients who are decisionally incapacitated. Most often, they rely on family to assist them in choosing what the patient would have wanted. In this vignette-based study, the ability of proxies to choose as the patients reported they would have chosen is called into question. Implications for the use of advance directives for end-of-life care and avenues for needed research are discussed.

Ethical issues surrounding decisions to limit treatment often focus on dramatic and highly technical interventions, such as mechanical ventilation. Many less dramatic forms of therapy are considered routine, and ethical aspects of their use may be less closely examined. Nutritional support can be crucially important in elderly patients, especially the very frail. Yet, appropriate use of nutritional therapy must consider the circumstances of an individual patient. Where severe underlying illness cannot be reversed, technical means of providing nutrition can represent extraordinary rather than ordinary means of prolonging life. The following case examines the ethical issues in respecting the apparent refusal of nutritional support by a severely debilitated geriatric patient.

The disciplines of bioethics and geriatrics have had parallel development in recent years. From small and relatively esoteric fields 15 or 20 years ago, both have grown enormously. Although the numbers of geriatricians and ethicists in practice or in academic centers have increased substantially, these disciplines represent areas in which better understanding is sorely needed. This bibliography is intended to assist the clinician in locating salient literature concerning bioethical issues in geriatric medicine and research. It is highly selective; it does not attempt to cover all the literature on bioethics. There are several excellent general bioethics bibliographies for clinicians in the recent literature, as well (not limited to clinical journals or clinical topics), some of which are included in section 13 for the reader's further information. The ethical issues that arise in geriatric medicine are similar to those that arise in the care of younger patients, but certain kinds of problems happen with far greater frequency. Dilemmas concerning decisions about care at the end of life are particularly relevant in geriatrics, as persons of extreme old age are often presented with choices about life-sustaining therapy when critical illness occurs. This includes decisions about cardiopulmonary resuscitation and nutritional support. When these clinical decisions arise in the care of patients who cannot decide for themselves, the question arises as to what role the assessment of "quality of life" ought to play in decisions to pursue or to forego life-sustaining therapy. Informed consent to treatment and to participation in research has been an important area of ethical investigation. Dilemmas about consent to treatment are complicated in some elderly populations because of the higher incidence of cognitive impairment and the higher incidence of the clinician's suspicion (or assumption) of cognitive impairment. In consent to research, there are additional issues of voluntariness and equitable selection, especially when subjects are residents of nursing homes. Because of the increasing numbers of elderly persons in our society, and because of the role of social resources (federal, state, and local) in acute and long-term medical major concern in gerontologic bioethics. The topic headings for this bibliography reflect these common issues which arise in the care of the elderly.+2

There has been increasing interest in the use of nursing home policies and guidelines to improve decisions about the elective use of life-sustaining treatments. Such policies should be based on a sound and complete understanding of the legal and ethical governance responsibilities of health care facilities. Policies should address both the process of decision making and treatment plan implementation. Nursing home administrators should commission policies and monitor their implementation.

The role of health care professionals in educating the public and policymakers about nuclear weapons, nuclear war and issues involved in preventing thermonuclear warfare is increasing. It is based on the professional and ethical responsibility to promote public health and prevent epidemic disease and death wherever possible. In the case of nuclear war, which has been called "the final epidemic," increased public knowledge is a primary method of working for its prevention. Policymakers in the United States and internationally are turning to physicians and scientists with important questions about the effects of nuclear war, questions about human behavior under stress, questions about long term ecological effects and survivability, and questions about technical aspects of the weapons themselves. The profession itself is asking questions about its proper role in these issues and the ethical basis for political activity on behalf of public health. Thus, concerned physicians are seeking education in these areas. Many medical schools have developed courses, one of which is described here. Consensus on a core curriculum has been achieved and curriculum materials are now available.

Of 18 boys in Duncan kindred, 6 died of a lymphoproliferative disease. They exhibited a subtle, progressive combined variable immunodeficiency disease characterised by benign or malignant proliferation of lymphocytes, histiocytosis, and alterations in concentrations of serum-immunoglobulins. Infectious mononucleosis occurred during or preceding terminal events in at least 3 of the cousins. Fever, pharyngitis, lymphadenomegaly, hepatosplenomegaly, atypical lymphocytosis, and a spectrum ranging from agammaglobulinaemia to polyclonal hyper-gammaglobulinaemia occurred. At necropsy, the thymus gland and thymic-dependent areas in the lymph-nodes and spleen were depleted of lymphocytes. Diffuse infiltrates composed of lymphocytes, plasma cells, and histiocytes, some containing erythrocytes, invaded the haematopoietic organs, viscera, and central nervous system. In addition, 2 half-brothers had lymphomas of the ileum and central nervous system. Approximately half the boys, including the half-brothers, were affected, and girls were spared, implying sex-linked recessive inheritance. Various lymphohistiocytoses resemble Duncan's disease, but it is distinctive from them in the mode of inheritance or by histiological characteristics. This study suggests that the Epstein-Barr virus or other viruses triggered the fatal proliferation of lymphocytes and that progressive attrition of T-cell functions allowed uncontrolled lymphoproliferation.

The growing need for care of elderly persons demands research in biomedical and clinical areas, as well as health services, social science, psychology, and ethics. There is a special urgency for research into the problems that affect persons needing long-term care, and for research into the structures and patterns of the delivery of long-term care. There are ethical issues in all aspects of human subjects experimentation, but the long-term care setting raises specific ethical issues related to the dependency of the subjects and to the fact of institutionalization. Special considerations about equity, informed consent, the meaning of special protections, and confidentiality are among those needing attention. Research into these ethical issues can serve to enable better research, not simply to act as a barrier to research. Understanding the conceptual and historical bases of the special problems in long-term care research will serve to further the understanding of how to improve long-term care.

As the complexity, prevalence and visibility of ethical dilemmas in medical care of the elderly have grown, hospitals and nursing homes have attempted to develop mechanisms for responding to these difficult ethical issues. While it is known that many hospitals rely on education and advice provided by an ethics committee, little data exist on the responses of nursing homes, despite the unique nature of ethical issues in a long-term care setting. The present paper reports findings from a national survey of administrators of 4504 nursing homes in which mechanisms for handling ethical dimensions in patient care were investigated. Results from 29% of respondents reveal that few nursing homes have established ethics committees (2% of the sample) and that committee formation appears positively associated with facility size and religious affiliation. Committees that have been formed engage in policy review (81%), advisory case review (67%) and education (45%). Few committees include patients or their representatives as members, and few have the authority to make binding decisions (26%). While the most effective response to ethical issues in medical decision-making is being debated, standing committees provide one means to contribute to the quality of decision-making by patients, their family members and their physicians. However, broader inclusion of patient perspectives and education of members regarding ethical analysis are necessary precursors to effective functioning of ethics committees in long-term care.

The role of the physician in the allocation of health care resources has come under renewed scrutiny in recent years. Doctors have always had to face the reality of scarce resources and to do their work in the context of social injustices. With the advent of Medicare and Medicaid came the rhetoric of universal access and the "right to health care." At the same time the field of bioethics was emerging and contributing ideas about other kinds of rights, such as the right to die with dignity. Physicians during this time did not see their role as that of gatekeeper, but rather as advocate for the best care for each individual patient. The 1980s has brought a new awareness of limited resources and the necessity for a rationale for allocation of resources. These social and professional shifts have confronted physicians with the need for yet another shift in their ethical stance. If they are to take part in allocation decisions, for the continued well-being of their patients and of the public health, they will need a new perspective on biomedical ethics. This role can be an ethical one for physicians providing certain criteria are met: there must be universal access to a basic minimum level of care, physicians' levels of income must not be directly related to treatment choices, there must be a closed financial system within which meaningful trade-offs can be made, and there must be an ethically acceptable framework for decision-making.

It is the authors' premise that caregivers of the suicidal elderly patient are at times guided by a paternalism that is not always in the best interests of the patient. They advocate instead care based on greater respect for the autonomy of the patient. A case of a suicidal, recently widowed man is presented, and historical and ethical considerations of bereavement and suicide are discussed.

Medical decisions are increasingly shaped by financial considerations. Biomedical ethicists have encouraged the practicing physician to remain the agent of the individual patient, sometimes pitting physicians against health care institutions. The limitation of medical resources has given rise to the need for a clear conceptual basis for allocating scarce resources. The role of resource gatekeeper may be used to the indigent patient's disadvantage when the principles of triage are used incorrectly in situations of relative scarcity. To allocate limited resources fairly under changing policy and economic conditions, health care institutions should ensure that systematic processes, such as those of ethics consultants and committees, are readily available to help resolve problematic cases and policies. Physicians with clinical judgment and a primary commitment to patient care must assume active roles in these processes in order to build an ethically sound framework for clinical decision making in times of relatively scarce resources.

Physicians have a specific responsibility toward patients who are hopelessly ill, dying, or in the end stages of an incurable disease. In a summary of current practices affecting the care of dying patients, we give particular emphasis to changes that have become commonplace since the early 1980s. Implementation of accepted policies has been deficient in certain areas, including the initiation of timely discussions with patients about dying, the solicitation and execution in advance of their directives for terminal care, the education of medical students and residents, and the formulation of institutional guidelines. The appropriate and, if necessary, aggressive use of pain-relieving substances is recommended, even when such use may result in shortened life. We emphasize the value of a sensitive approach to care--one that is adjusted continually to suit the changing needs of the patient as death approaches. Possible settings for death are reviewed, including the home, the hospital, the intensive care unit, and the nursing home. Finally, we consider the physician's response to the dying patient who is rational and desires suicide or euthanasia.

Testing for patients presenting with dementias can lead to diagnosis of disorders that can contribute to cognitive dysfunction, and to improvement, stabilization, or slowed deterioration in some demented patients. However, possible benefits must be balanced against possible costs. The present recommendations for workup of patients with dementia includes some tests with only marginal benefits, and a more limited workup may be as effective. This case demonstrates how important it is to be sensitive as well to possible effects on family relationships of demented patients. When we evaluate and treat demented patients, the dependence of the demented patient on the caregiver and the emotional and physical stresses experienced by many caregivers make it important to consider the patient and caregiver as a system vulnerable to many potential risks.

When a cognitively-impaired elderly man nearly caused a serious fire at home through his inappropriate use of a gas oven, the incident raised questions about his capacity to live alone. Although he clearly wanted to preserve his independence, the health care team felt obligated to assure his safety. The following discussion of dangerous behavior in a demented elderly man elicits and portrays these conflicting values, and highlights the physician's obligations in such ethically and legally complex situations.

Practicing physicians are frequently faced with the question of whether or not to institute cardiopulmonary resuscitation in case of cardiac or respiratory arrest in a patient in hospital. Medical training has usually not included any systematic analysis of this issue from either an ethical or a legal standpoint. Many physicians may be unaware that ethical and legal principles, as well as professional guidelines, exist to guide such decision making. In practice, physicians make this decision without the benefit of training in ethical analysis. The problem is especially acute in teaching hospitals when young physicians unacquainted with formal ethics or the law must often make decisions emergently. Studies show some discrepancy between ethical and legal principles and the actual decision making by physicians. For this reason, we recommend an approach that will enable physicians to make and implement decisions not to resuscitate that are consistent with current ethical and legal standards.

To identify treatment-withholding intentions for 56 VA medicine inpatients who received a no-code order, 31 resident physicians who wrote the orders completed a checklist on which they indicated the interventions they intended to withhold from each patient. Review of patients' charts indicated that 24 (43%) contained no documentation of treatment limitation plans beyond the no-code order. To identify the general interpretations of no-code orders, "cross-covering" physicians indicated on a questionnaire the likelihood that they would withhold specific interventions from patients they were covering who had received a no-code order. Both the intention and interpretation of no-code orders were characterized by variability, and interpretation of the orders was characterized by uncertainty as well. Because of these discrepancies, we suggest a no-code order which provides greater specificity for individual patients.

Dementia creates special ethical dilemmas and affects common ethical problems. In this article, the authors outline the clinical course of a demented patient in order to examine how different ethical issues tend to arise in different stages of dementia. The topics of accurate diagnosis, treatment planning (including advance directives), assessment of decision-making capacity, recognition of caregiver problems, and addressing end-of-life concerns are highlighted through the patient's case history. The setting of these ethical problems in the context of American society today and the special ethical issues in dementia research are also explored.