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Communication and informed consent in elderly people.

Physician-patient relationship is the key-point for an optimal management of any medical procedure. Before performing any diagnostic or therapeutic procedure, clinical communication with patients is necessary. It should regard the nature and purpose of a proposed procedure including potential risks and benefits. During physician-patient communication, alternatives, as well as the risks and benefits of not receiving or undergoing a procedure should also be disclosed. Thus, a complete physician-patient clinical communication is the basis of "shared decision-making" and plays a clinical-therapeutic role in the informed consent process in order to improve patient care. Informed consent is a delicate process of communication between a patient and physician necessary for patient authorization for any medical intervention. The success of achieving good informed consent procedure depends on the strength of the relationship between the doctor and the patient. For this reason, the traditional paternalistic relationship, in which decisions were made by the doctor, is no longer appropriate. Therefore, the use of a model which allows for a greater patient involvement in the decision making process is fundamental. This approach allows for a clearer impact on patient values. The aspects of the procedure related to these values, combined with the technical and scientific considerations of the doctor, are the basis of a shared decision making process, in which the patient is actively involved. Therefore, an informed consent is not simply the acquisition of the patient's signature, but a real process based on the dialogue between doctor and patient. This dialogue is particularly delicate in some circumstances, such as geriatric medicine and anesthesiology. Seeking consent is part of a respectful relationship with an older person. Adults are almost always considered capable of making personal healthcare decisions. Older adults should also be considered capable of handling their own healthcare where the idea that old age or frailty may inhibit ones' decisional capacity. It is essential to provide appropriate and accessible information for each individual case in order to confirm patient comprehension, especially in the presence of possible coexisting disabilities (i.e., cognitive impairment, presbyacusia, visual disturbances, etc.). The informed consent process should therefore be adapted to patient understanding linked to level of education, and personality. Cognitive impairment may limit the ability to actively participate in the process. In this context, physicians deal with three different situations on a daily basis: 1) patients with good cognitive functioning; 2) patients with various degrees of cognitive impairment; 3) patients with a legal guardian. The aim of this review was to discuss patterns of an accurate, empathetic and effective communication process that may be used during the informed consent process with a particular attention to the emerging problems in the practice of anesthesia in the elderly.

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