College of Medicine, California Northstate University, Elk Grove, California.
Division of Geriatrics, University of California, San Francisco, San Francisco, California.
J Am Geriatr Soc. 2019 Aug;67(8):1724-1729. doi: 10.1111/jgs.15957. Epub 2019 May 6.
The decision-making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision-making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders. J Am Geriatr Soc 67:1724-1729, 2019.
代表无能力成年人（即缺乏做出医疗决策能力且没有可识别代理人的成年人）做出决策的过程存在风险，因为其利益可能未被纳入考虑，从而引发伦理问题。我们对一个城市县内多个领域的关键利益相关者进行了半结构化访谈，这些利益相关者参与了无能力成年人的护理或决策过程。这包括一个医疗保障系统、社会服务和法律服务。参与者包括与无能力成年人一起工作的医疗、社会服务和法律专业人员（n = 25）。我们的访谈问题探讨了无能力成年人代理决策的当前流程和潜在替代方案。我们使用恒定性比较方法记录、转录和分析访谈，以确定如果提出潜在的伦理挑战，与之相关的主要主题。参与者围绕无能力成年人的护理面临着多个伦理挑战。参与者描述的主题包括：（1）优先考虑自主权；（2）不同的安全阈值；（3）公平分配资源；（4）对利益相关者造成道德负担。总之，所有利益相关者都在照顾无能力成年人方面发现了伦理挑战。考虑到这些困境的应用伦理框架可以改善无能力成年人的伦理实践，并减轻利益相关者的情感负担。《美国老年医学会杂志》67：1724-1729，2019 年。
