Chapter 1: Introduction
Every patient is unique and different as my Professor once said during a lecture in undergraduate school. As time goes, and training enhances in the clinical aspect of medicine, we start realizing that it is not only the disease which is different but also the persons involved. The acceptance or refusal of treatment by patients varies from patient to patient depending on the factors to be considered. Often it falls back to the doctor to offer exclusive explanation to the patients in order for them to give their consent for the health care procedure to proceed. Most often the decision-making process involves the patients themselves, though in the case of the elderly and children, third parties may be involved.
The focus subject for this paper is elderly patients especially those who are above 60 years old. Elderly patients often with chronic diseases tend to have various issues including communication, dealing with family members who would want to join in discussion with doctors, sharing advice and making medical decisions.
The advancement in medicine and technology has blessed the elderly population with longer health compared to years before. Various issues of population aging however have been extensively discussed here in Malaysia and countries such as America. In the years to come, the loss of health and life in every region of the world will be higher from non-communicable conditions such as Heart disease, cancer, and diabetes. This represents a change in disease epidemiology that has become the focus of attention in view of global aging.
Raw data shows a significant increase in aged patients globally and to be specific in 1950,global data showed that there was about 205 million persons above the age of 60, and fifty years later in year 2000 there is about 606 million with America, china and India leading the way. In America the older population person 65 years or older numbered at 39.9 million about one in every eight Americans. There is speculation that this number will increase to 72.1 million by 2030. Meanwhile latest data in Malaysia Showed that the proportion of population age over 65 has increased to 5.1 percent from 3.9 percent from year 2000. The elderly population is different in its nonhomogeneity which includes physical and medical heterogeneity increase with advancing age. Data analysis by age however supports the relevance of usually defining patients aged more than 64 years old as elderly. Initial results and longterm clinical and angiographic implications of coronary stenting in elderly patients. The majority of aged patients will be living throughout their old age with various chronic diseases such as diabetes mellitus, hypertension, dementia, kidney failure, cerebrovascular disease and other which depending on status will require help at different levels from state, family members, relatives and such. Almost 15% of the Western population and about 25% of surgical patients are aged 65 yr. More than half of the patients will in any part of their lives undergo surgery in the remainder of their life time. Age itself is an independent morbidity and mortality risk factor for a long list of diseases and injuries, hospitalization, length of hospitalization, and adverse drug reactions. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.
1.1.1 Malaysia and an ageing population.
Looking at statistics in Malaysia the number of persons above the age of 65 Years and showed a rise by 1.82% in year 1990, another 2% in year 1991 till 3.4% in year 1992. It was estimated that the growth rate for this portion of the population was2.4% from 1990 till 1993. This rate showed an accelerated growth over the 1991- 2000 period when 990,000 Persons were 65 Years and above by the year 2000 which is 4.4% of the total population (year book of statistics, Malaysia). This percentage however is expected to rise up to 9.9 percent by year 2020 and Malaysia is expected to have a population of elderly of 15 percent by 2030.With this number however, we must be prepared to face social issues which usually crop up with elder population. A survey by National population and family board in 2004 noted that substantial amount of elderly parents do not receive any welfare or financial aid from their children. At the same time, Social Welfare Departments are reporting that the number of abandoned old folk had risen by 1 per cent each year between 2008 and 2011, based on the number of admission to the nine Rumah Seri Kenanagan homes, the welfare homes run by the Ministry for abandoned senior citizens.
Various quarters have raised concern on whether the current healthcare setting, which mostly focuses and invest on dealing with acute medical problems, is preparing to face the health concerns in an increasing elderly population. Various Non-Governmental organizations and our government however have been very active in their approach by setting short and medium goal and developing policies and service related to the ageing population.
1.1.2 Impact of the ageing population on Malaysias Healthcare.
In relation to the increase of ageing population and presence of non-communicable diseases it impacts healthcare in various ways. These includes increasing personals trained in this area, finance, increase of facility specialized in treating geriatrics patients, increase of homes which cares for them. A more acute problem is however the need to increase manpower in caring for elder patients. These personnels will require specialized training in the area of geriatrics. Currently in Malaysia we see a lack of Geriatricians and staff nurses trained in this area. There are only 16 doctors in Malaysia who are trained in this area to provide service to the 7% ageing patients of Malaysias population. When we speak of increasing personals in this area will require proper training which directly impacts the need for facilities, funds, and trainers to provide the required amount of Healthcare service to the elder patients.
However once we have addressed the above mentioned challenges, we will be looking an increase of medical procedures and treatment for the elder patient. This requires looking into the focus of this research which medical decision is making by the elder patients. Once living with such diseases becomes imminent aged patient are left with making daily important medical decision from choices of treatment, surgery, medication etc. Therefore it is utmost important that the decision made by aged patients in regards to treatment proposal by Healthcare practitioners is one which is well informed to be able to make that best choice. Making the best choice however is a process which requires various consideration and information to be able to reach the right choice. A very important role is played by the doctor in assisting the patient in making the best choice, which also includes assessing the patient mental capacity or competency and their needs. Therefore with the increasing number of aged group patients, there is a need to understand what the preferences and choices of the adult patient are when making a medical decision and whether they are reflected in the law of medical decision making in Malaysia.
As humans we are bound to make personal choices in the way our lives are sorted out. Health behaviour is determined in part by perceptions of control over performance of the behaviour which will vary from individual to individualthese choices ranges from values such as your attitude, self-esteem, religion, lifestyle, marriage, job and various other factors. This research that will be undertaken will seek to understand various values that adult patients attach significance to when making medical decisions. This will done by examining the legal perspective of competency assessment in cases like Re-c, Re-T and how much personal value affected decision making of patients.
Richard Homans article autonomy reconstructed is also relied on in which he explains how the various cognitive, psychological, and emotional developments we have gone through and achieved from birth have an impact on how as fully competent adults we make decisions. He advances the idea that our conception of autonomy is very much influenced by our personal history.
1.2 Hypothesis and research question.
A significant article in regards to medical decision making was published in Free Malaysia today dated February 7th 2015 titled Canadian courts say patients have right to die, strikes down ban speaks about the supreme court of Canada who has overturned a ban on physician-assisted suicide. The top judge cited that,
A mentally competent, consenting adult who have intolerable physical of physiological suffering from a severe and incurable medical condition have the right to a doctors help to die. The disease does not have to be terminal
The first part of the judgement above is to task the treating doctor on whether the patient is competent patient first before allowing his/her decision. This is to ensure the patient is not being coerced or the decision is influenced by drugs or mental health diseases. This however opens up a wide gap which requires a clear interpretation of competency of patients and medical decision making which isnt available in our law yet. What is it that reflected as mentally competent person, and does our laws pen out a clear guide on determining a mentally competent person. If the gap is not addressed properly it could lead to misuse or poor interpretation where every patients are allowed consent to have physician-assisted suicide.
A related question is also whether adult preferences and choices has an impact on medical decision making and is it taken into account in our law through legal principles? Doctors play a vital role in determining the validity of this decision since among the various factors which could influence the patients decision making is the explanation on the advantages and disadvantages of that particular therapeutic procedure as well as the chances of the treatment being successful. These factors include:
Is the patients decision influenced by other parties (autonomy)?
Does the patient have adequate information to reach a decision?
What are the guiding principles for the patient to reach a decision etc Science, religion and so on?
My research question is, does the law state very clearly the principles to be followed by patients in the decision making process concerning therapeutic procedures? The focus would be on medical decision making in adult patients.
The hypothesis is that the interpretation of capacity of patients to make decisions concerning treatment in the law especially in Malaysia is too narrow and unclear and will require expansion, including the addition of patients values and beliefs among other things, so as to minimize if not terminate refusal of treatment by patients. Other areas that would be covered in the discussion include principles of bioethics.
1.3.1. Research statement.
The current law and practice in assessment of medical decision which mostly is an assessment of cognitive function of retaining information and balancing needs and risk is rather narrow compared to additional patient values which plays a significant role.
To asses some common factors which adult patients are likely to consider in medical decision making and examine whether these factors are accurately reflected and embodied in the law, and whether the entire decision-making process exclusively covers all patients needs.
Specific Objectives.To describe and compare both the medical and legal assessment of adult patie...
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