Ethical Considerations in Electronic Monitoring of the Cognitively Impaired

Y. Tony Yang; Charles G. Kels

doi:10.3122/jabfm.2017.02.160219

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Table 1.

Typology of Electronic Monitoring for Cognitively Impaired Individuals

Technology	Characteristics^7,8
GPS	∙ Device receives satellite signals to calculate wearer's position, then relays it to the appropriate party ∙ Highly accurate ∙ Covers large areas ∙ Requires clear path/unimpeded signals ∙ Enable virtual boundaries that trigger an alert when crossed ∙ Speed and accuracy can be augmented with Assisted GPS or Bluetooth technology ∙ Examples: GPS Smart Shoe, Tracking System Direct wristwatch, Comfort Zone mobile phone, Keruve wristwatch and receiver, Project Lifesaver Protect, and Locate digital watch and receiver
Radiofrequency	∙ Device emits radio waves to a locating antenna ∙ Signal detectable on ground or by air ∙ Receiver must be tuned to the appropriate frequency ∙ Limited signal range ∙ Can be manually activated or used to create a virtual boundary ∙ Radiofrequency identification creates a “tag” to track individuals each time they pass through an area ∙ Examples: Project Lifesaver locating device, LoJack Safety Net
Cellular triangulation	∙ Device connects to the network and communicates with cellular towers ∙ Connects with the closest tower to conserve power ∙ Assisted GPS combines cellular and satellite positioning

GPS, global positioning system.

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Table 2.

Ethical Considerations and Recommendations in Electronic Tracking of Cognitively Impaired Individuals

Ethical Principle	Concerns in Electronic Tracking	Best Practices for Developing Care Plans
Liberty^1517–18	∙ Virtual boundaries or alarms may function as restrictions on movement	∙ Consider how electronic tracking may obviate or postpone the necessity of more restrictive care settings¹⁷ ∙ Assess how remote monitoring may replace physical barriers and enhance freedom of movement^18,19 ∙ Incorporate tracking into care plans to promote, rather than restrict, independence¹⁸
	∙ Susceptibility of tracking technology to overuse
	∙ Appropriate balancing of technological intervention against safety risk
	∙ Constraining effect on choices and activities
	∙ Remote monitoring may prolong independent living
	∙ Enables less restrictive care settings
	∙ Less intrusive than physical obstructions
	∙ Reassuring safety net for individuals
Privacy^15,16,18,20	∙ Devices enable constant surveillance	∙ Consider whether lower-technology solutions that invade privacy less may be sufficient (eg, registration systems, personalized identification cards, emergency response services that can be activated by phone) ∙ Limit access to tracking data to only those who need it and/or those whom the individual wants to receive it¹⁵ ∙ Ensure tracking system is secure¹⁷
	∙ May conflict with individual's past/present views on privacy
	∙ Monitoring can facilitate care in more private settings (eg, home vs nursing home)
	∙ Individual may value privacy differently depending on the actor (eg, caregivers, family, fellow patients)
Dignity^15,16,18,20	∙ Tracking devices may have negative connotations (eg, criminal justice, animals, packages, “big brother”)¹⁸ ∙ Perceptions of tracking devices may be shaped by their association with wandering or dementia ∙ Electronic monitoring may help prevent stigmatizing episodes of wandering¹⁴	∙ Differentiate “best interests” and “best medical interests,” especially where the latter may impinge on the former¹⁴ ∙ Ensure devices are discrete¹⁸ and part of an overall plan that is individualized and consistently reassessed¹⁷
Respect for persons, including autonomy^18,20–22	∙ Individual's capacity to consent may be compromised and fluctuating¹⁵ ∙ How and when the cognitively impaired individual is engaged in discussion can be critical²⁰ ∙ Efficacy of the device may rely on the cognitively impaired person remembering or choosing to affix it before walking	∙ Avoid deception, in terms of both hiding the device or concealing its purpose from the cognitively impaired individual¹⁸ ∙ Assess acceptable levels of risk to the cognitively impaired individual, loved ones, and caregivers²³ ∙ Convene the cognitively impaired person, loved ones, and caregivers as a collaborative team when feasible and as early in the stages of degenerative impairment as possible ∙ Maximize the cognitively impaired person's involvement and input, irrespective of ability to consent^17,24
Beneficence²¹	∙ Wandering poses significant risks of morbidity and mortality to cognitively impaired persons but can also be beneficial ∙ Mitigating risks for cognitively impaired persons may necessitate foregoing benefits valued by the individual^20,23 ∙ Concerns about wandering may compromise caregiver well-being^15,18	∙ Consider reasons for the cognitively impaired person's wandering, including whether it is a manifestation of an unmet need (eg, exercise, companionship)¹⁵ ∙ Counsel that surveillance is not a quick fix or substitute for personal care, but part of a comprehensive care plan^15,17