Ethics, Legal Issues, and Long-Term Care Systems
What to know
Core ethical principles: autonomy, beneficence, nonmaleficence, justice. Capacity is decision-specific and assessed clinically; competence is a legal determination. Informed consent requires capacity, information, and voluntariness. Advance directives (living will, durable power of attorney for health care) and POLST guide care. Elder mistreatment (physical, emotional, financial, neglect) mandates reporting in most jurisdictions. Long-term care settings: home and community-based services, assisted living, skilled nursing facilities, and hospice. Nursing home regulations and quality measures matter. Guardianship is a last resort. Confidentiality and HIPAA apply. Goals-of-care conversations should be documented.
Traps
Don't equate capacity with a dementia diagnosis-many patients retain capacity for specific decisions. Don't ignore suspected elder abuse; reporting is mandatory. Distinguish advance directive (future) from POLST (current actionable orders). Respect autonomy even when the choice seems unwise, if capacity is intact. Guardianship should be least restrictive.
Rule of thumb
"Capacity is decision-specific and time-specific": assess the specific choice, not the person globally.
Worked example
A patient with mild dementia who wants to refuse a procedure: assess capacity for that decision; if intact, honor autonomy. If not, involve the health care proxy and document.
Worked example 2
Suspected financial exploitation by a family member: report per mandatory elder-abuse laws and involve social work.