Medical care for elderly patients with diminished competence: an ethical analysis.

The moral responsibilities of physicians caring for elderly patients of diminished or marginal competence are analyzed. In the context of two case studies, it is argued that these responsibilities are not grounded simply in the patient's best interests as the physician understands them. Instead, they should be grounded in the patient's past autonomy, that is, the values and beliefs that the patient held prior to the loss of competence. Family members have a key role to play in assisting the physician to construct this "value history." An important role for the patient's primary care physician is also identified, namely, developing the patient's value history in advance with the patient while he or she is competent, and recording that history in the patient's chart.