Ethical and legal issues

| The doctor is the one who generally makes the decision but it must be made based on the cinoc basic principles of ethics

Although there are cultural differences in terms of ethical requirements, decisions are made by the doctor, the elderly and / or their family, and the state or community.

The doctor is the one who usually makes the decision. This must be done based on the basic principles of ethics, which are:

• Principle of beneficence: it is the obligation to do good to the patient, seeking his greatest benefit.
• Principle of non-maleficence: You are morally obliged not to institute procedures that are clearly contraindicated, not even with the consent of the patient. Avoid applying extraordinary or disproportionate means that could suppose a therapeutic cruelty.
• Principle of autonomy: defends the freedom that the individual has, no matter how bad it is or how many years it has, to establish its own norms, values ​​and make decisions.
• Principle of justice: which is related to the mandatory compliance with the laws that society has established. Benefits may be restricted as inappropriate, expensive, or scarce treatment, even when required by the patient, as available resources are limited. Here the person in charge is the Administration.
• Principle of truthfulness: the doctor must provide the elderly with accurate, real and adequate information, in order to obtain their informed consent on the diagnostic or therapeutic procedure to be performed. The old man must be told "everything he wants to know and only what he wants to know", and that everything that is said is true.

The elderly patient is undoubtedly the key piece of the decision to be made in geriatric care, so it will always be necessary to involve them in the decisions as far as possible. In order for you to be able to decide freely and adequately, it is first of all necessary that you have the capacity to grant your informed consent. Informed consent can be reflected in some procedures through written forms, such as blood transfusion, or in the medical history. The elderly are considered capable when they meet four requirements:

• Being able to express a choice through oral, written or gestural language.
• Understand and take into account all the relevant elements related to decision making.
• Appreciate the importance of the disease, believing the information and its significance.
• Reason for this decision logically.

Unlike capacity, competence is an ethical-legal concept. Deciding whether a person whose temporary absence of natural ability to act lengthens over time and tends to become permanent is a more legal decision than a clinical one. In some cases, the one who makes the final decision on jurisdiction, if there is a conflict, is the judicial authority.

The family must be a complementary element when making a therapeutic decision, involving it in decision-making in the event of incompetence of the patient and transmitting the information that the patient accepts and who authorizes. However, in most cases, except for serious family conflict, decisions are made jointly, among all. Unfortunately, there is still a lot of taboo in families and even among health professionals towards truthful information to patients, respecting their right not to know.

Taking into account that the end of aging is death and that the fact that as long as there is hope there is life (and not the other way around) must prevail, it is important to take into account several considerations at the end of life:

• Both direct and voluntary active euthanasia and assisted suicide are criminalized by the penal code and are contrary to ethics and deontology. Direct active euthanasia is the act of causing the death of a desperately ill person, who is suffering, relatively quickly and painlessly for compassionate reasons. Assisted suicide is the intentional help of a patient to end his own life at his own request.
• Indirect active euthanasia or adistanasia, consisting of terminal sedation, to contain symptoms and facilitate a dignified death, is not penalized by the penal code. Neither is passive euthanasia penalized in its two forms: orthothanasia or withdrawal of futile or non-indicated medical treatments or the omission of administering treatments that have proven to be ineffective or contraindicated in the final moments, such as artificial feeding. The objective of the decision to be made will never have to be the avoidance of the feeling of guilt, but the well-being of the patient.
• No one should ever die alone or in pain or discomfort. Care should preferably be given at home or in the hospital according to the preference of the elderly, and secondarily to their relatives or caregivers.