Ethical issues in emergency care.

The ethical framework established for most health care decision making should apply to elderly patients in the ED, i.e., the authority to decide should rest either with the competent patient or, in case of incapacity, with the patient's surrogate. Whenever possible, ethical dilemmas in the ED should be prevented from occurring through the judicious use of advance directives crafted in the doctor's office. DNR orders should be based upon the wishes of a competent patient or upon a surrogate's estimation of the patient's values and best interests. Because advanced age is a predictor of poor outcome for most hospitalized elderly patients, physicians should educate themselves about the actual benefits and burdens of CPR in this population and share this information with patients and surrogates. In case physicians determine that CPR would be futile in a strict sense, they have no ethical or legal obligation to administer it, even if requested to do so; however, they have an ethical obligation to inform the patient or family of the reasons for the decision and should offer the family the option of dispute mediation in case of disagreement. If the patient arrives in the ED capable of making decisions but lacking an advance directive, it is the responsibility of physicians and nurses to educate the patient concerning the respective merits and drawbacks of the living will and health care proxy. Except for those elderly patients who lack family or friends or who do not wish to burden others with such decisions, the health care proxy, supplemented perhaps to some extent by oral or written specific directives, appears to be the best approach. Attention to these important problems bearing on the substance and procedures for life and death decision making in the ED should not obscure the manifest injustice of the context in which these decisions are often made. At many inner-city hospitals serving a largely poor and elderly clientele, the ED has become nothing short of a torture chamber for many critically ill elderly persons. An ethical framework for decision making, no matter how urgently needed, will not address the unnecessary pain and confusion of frail elderly patients subjected to an impersonal, overcrowded, and depersonalizing environment.