Ethical Issues in Gerontology

Nowadays, nurses who provide elder care are faced with several legal and ethical dilemmas in a daily basis. Besides to the social and legal dilemma it creates, elder abuse, neglect or also known as elder mistreatment is a massive health care crisis that can lead to long term health complications and even death (Fulmer & Greenberg, 2012). The purpose of this paper is to review the literature and examine the nature of elder abuse in relation to its legal and ethical implications. Furthermore, this paper is intended to discuss the causes and types of elder abuse; professional responsibilities related to reporting, documenting, and intervening in cases of suspected abuse. Finally, this paper will highlight some strategies that will potentially prevent elder abuse.

Literature Review

CINAHL and Pub Med databases were used to find the existing studies about elder abuse and the legal and ethical responsibilities of health care providers and family caregivers. The keywords such as elder abuse, legal, ethical and healthcare providers obligations and responsibility were use to search the data. Elder abuse is a medical and social concern. As a result many studies are found in social study journals and books. The true national incidence or prevalence of elder abuse is not known although various studies have attempted to specify the size of the problem. However, all the studies found highlights that it is a serous health problem that affects the quality of life many older adults. The studies regarding elder abuse and mistreatment are incorporated through out the paper. Overview discussion of elder abuse

Elder abuse is defined as “an act of physical or mental maltreatment that threatens or causes harm to an elderly person whether by action or inaction” (Luggen & M, 2001, p. 216). It can involve both intentional and unintentional acts that cause bodily harm or create a serious risk of harm such as emotional abuse, exploitation, physical abuse, sexual abuse as well as the failure of a family or paid formal caregiver to provide an elder under their care with basic needs leading to neglect or abandonment (Lachs & Pillmer, 2004). Canada is home to an increasingly aging society. In 2009, statistics Canada reported that 13% of the Canadian population was over the age of 65. Today, theses fast growing populations of older adults are often more visible, active, and live independently than ever before. However for some older adults instead of enjoying their late life, behind drawn curtains and closed doors they are becoming victims of elder abuse (Statistics Canada, 2010).

Elder abuse is not a new phenomenon. Although, the true prevalence and incidence of elder abuse is not well known due to factors such as under-reporting, denial both by the victim and perpetrator, confusion about what constitutes abuse, or a general lack of awareness of warning signs about the issue, it happens in all communities, among every race, culture, and religion (Ebersole, Hess, Touhy, Jett, & Luggen, 2008). Currently, this serous health problem is recognized worldwide as a persistent and rising problem, valuing the attention of health care providers who provide medical care for seniors, governments as well as the general public(Lachs & Pillmer, 2004). According to The World Health Organization (WHO) it is estimated that between 4 and 6 per cent of older adults worldwide have suffered some form of elder abuse —either physical, psychological, emotional, financial or due to neglect.

In Canada, the overall rate of police reported violence against elders has increased by 20% between 1998 and 2005 (Statistics Canada, 2010). Similarly, in the year 2009 7,900 incidents of elder abuse were reported to police, a number that had increased by 14% since 2004 (Statistics Canada, 2010). Although a steady rise of reported cases are seen, cultural influences may affect how abuse is manifested and perceived, and how the members of the culture respond to abuse (American Psychological Association, 2006). This can lead to gross under-reporting of the issue. The Canadian health care system spends about 4.2 billion dollars to address and treat violence (Center for research on Violence Against Women and Children, 1995). Hence, In addition to the obvious economic impact, elder abuse can profoundly affect emotional well being, quality of life, and even in some cases a loss of life.

Elder abuse in home setting

Elder abuse is an important health issue for seniors in Canada. It can affect seniors in all communities, races and social statuses (Ebersole et al., 2008) However, some elders those who are older, female, isolated, or dependent on others for personal and financial care may even are more at greater risk (American Psychological Association, 2006). In addition, those who are under the care of someone with an addiction, seniors living in institutional settings, and those who are frail, and have a physical or cognitive disability may be mostly vulnerable (Fulmer & Greenberg, 2012). Elder abuse at home setting usually involves the maltreatment of an older person by someone who has a unique relationship to the elder. This relationship includes spouses, children, siblings, friends, or caregivers (American Psychological Association, 2012). According to Statistics Canada (2009), of all the incidence of abuse reported to police, approximately one third were committed by family members of the elderly person (most commonly a grown child or spouse), one third were committed by friends or acquaintance, and the rest one third were committed by a strangers.

The cause of elder abuse is multifaceted. Generally, a combination of psychological, social, and economic factors, as well as mental and physical conditions of the victim and perpetrator contribute to the occurrence of elder abuse Wagner, Greenberg, & Capezuti, 2002 as cited on (Fulmer & Greenberg, 2012). In the developing world family members provide 60% to 80% of long-term care of their elderly significant others (American Psychological Association, 2012). Consequently, the burden of providing constant physical care needs such as toileting and bathing can be particularly stressful. The complexity of providing care to a physically, cognitively or emotionally impaired elderly individual can also be tremendous. Depression, confusion, Alzheimer’s disease, or incontinence on the part of the aging person can make care giving especially overwhelming ((American Psychological Association, 2012).

According to American Psychological Association (2006), in addition to providing in average 20 hours a week at home on care giving responsibilities, about 64% of those family caregivers work either part time or full time out side of home. As a result, the caregivers often suffer from interrupted sleep, chronic fatigue, little or no privacy, and disintegrating personal lives. (National Center for Elder Abuse, 2011). Furthermore, abuse can often escalates when the care giver faces economic hardships, such as unable to pay the cost of health care services for the aging parent, or economic recessions. This creates stress, conflict and tension on the part of the care giver, leading to elder abuse. An elder is also more likely to be abused in a family that is more prone to violence as a learned behavior. Abusive behavior in these families is a normal response to tension and conflict since no other ways to respond have been adapted. Elder abuse in health care setting

Older adults living in long term care institutions are mostly elderly; the majority is in their late 80s or 90s. This includes a wide range of institutions, for example, personal care homes, nursing homes, homes for the aged and complex care facilities. According to the Public Health Agency of Canada (2007), about 7 percent of seniors over the age of 65 live in long-term care facilities, although this number is expected to increases to 14 percent for those over age 75. Furthermore, approximately 20-30% of all seniors will spend their last years in some form of care facility (Canadian Network for the Prevention of Elder Abuse, 2009). Therefore, nurses as elder care providers in these centers need to recognize the signs of abuse and understand the legal and ethical obligations in terms of identifying, documenting, reporting and preventing abuse.

According to The Ontario College of Nurses survey of 804 registered nurses and 804 registered practical nurses as cited on (Canadian Network for the Prevention of Elder Abuse, 2009) 20% of the nursing staff reported witnessing abuse of patients in nursing homes. Similarly, 31% of the nurses reported witnessing rough handling of patients. Furthermore, 28% of the surveyed nurses reported witnessing workers yelling and swearing at patients, and the rest 28% reported witnessing embarrassing comments being said to patients. Finally, 10% reported witnessing other staff hitting or shoving patients. Even though, most often elder abuse in institutional settings takes the form of physical, sexual or financial abuse, the majority reported acts of elder abuse in the health care setting are physical abuse. These acts can range from something relatively minor, to more serious falls and causing death (Canadian Network for the Prevention of Elder Abuse, 2009). Critique, Analysis and Personal Opinions

Institutional elder abuse often occurs in residential facilities (such as nursing homes, foster homes, group homes and long term care facilities) for older persons (Canadian Network for the Prevention of Elder Abuse, 2009). Usually, perpetrators of the abuse are individuals with a moral and legal obligation to provide elder victims with evidence based care and protection. Research has suggests that any type of elder abuse- physical abuse; sexual abuse; emotional abuse; financial exploitation; and neglect contribute to psychological and psychiatric conditions such as depression, post-traumatic stress and learned helplessness and alienation ((American Psychological Association, 2012) Case Study

As a nursing student working in a nephrology unit, I have witnessed an RN rough handling a frail, obese, 83 year old woman nursing home resident who also had a kidney problem. In that specific morning, I was assigned to care for the 83 year old women and she refuses her usual bath and asked me to have it later. At noon the patient demands to have her bath, and I was with my teacher discussing about my clinical progress. Then the RN Mrs. S who was my preceptor, came and was yelling at me for not completing my task. I told the RN that the patient Mrs, B wanted her bath later. The RN then said to me, she is confused, difficult and I do not have the time to do what ever she requested. I was in disbelief that the RN ignored the competent elder’s right to self determination and it is a violation of the primary ethical principal. Finally, I went to help the RN to bath the patient and then witnessed similarly yelling and rough handling the patient. As a nursing student, I did not understand the legal and professional responsibility I had in terms of documenting, reporting and intervening in the situation.

At that time my overwhelming sense of powerlessness and fear of how will I tell the abuser, and will she fail me and harass me in my clinical placement, had created a moral dilemma for me. In addition, if I do tell the manager about the situation, will the RN becomes more abusive to the patient, and also would the patient oppose reporting or intervening me in the situation created an ethical dilemmas for me. I found my self torn between the value of a patient’s autonomy (self determination) and my own professional ethic of beneficence (to do good). Finally, when I consulted my teacher, she ask me to examine the issue and read articles about what constitutes elder abuse, how to address it and confront the RN about the issue. More importantly, I came in realization that the patient’s right to self-determination need to be highly regarded, and legally preserved. This type of abuse is called emotional or psychological abuse which can range from name-calling or giving the “silent treatment” to intimidating and threatening the individual. When the care giver behave in a way that causes “fear, mental anguish, and emotional pain or distress, the behavior is regarded as abusive “ (American Psychological Association, 2012, para. 15).

Emotional or psychological abuse of an elderly person is often quite difficult to prove since there is usually no visible evidence of abuse. However, the consequence of the abuse is manifested in several ways. Victims most often report trouble sleeping or become withdrawn, non communicative, passive, agitated, or emotionally upset. Towards the end of my placement, I gave the unit a small presentation about types, signs and prevention of elder abuse, and the nurse’s legal and ethical responsibilities. After the presentation I confronted the RN, and she apologized and said that the unit was understaffed, and that the patient was uncooperative.

According to (Lachs & Pillmer, 2004) underpaid, under qualified and overworked staff within institutions that provide care to elderly may contribute to elder abuse. Currently, governments do not dictate staffing levels; however, Many times, the staff members in institutions feel powerless and the pressures and difficulties of the job are overwhelming. Staff members may react to these feelings of powerlessness and stress by becoming abusive to the elderly residents in the institution. Health care providers who work with the elderly must be trained in conflict resolution, so that violent responses to difficult situations can be avoided. Legal and professional responsibility

Legal and professional responsibility involved in the detection, documentation, and reporting of elder abuse can be difficult. A close working relationship with elders and their families can ensure that subtle behavioral signs indicating abuse will not be ignored, and encourage that an open communication will ensure a promptly intervention if problems occur. Cultural, religious, and ethnic differences must also be considered during the assessment and detection on elder abuse (Lueckenotte, 2000; Luggen & Meiner, 2001). When nurses are involved in the collection of evidence and the documentation of suspected abuse, it is crucial that they be trained in the importance of proper collection, adequate testing, and proper documentation.

Nursing documentation of suspected abuse is crucial. It should be clear, specific, and objectively noted the sings and symptoms of the abuse noted; use quotations (described as accurately as possible) since this minimizes liability issues; describe what actions were taken, by whom, when, where, etc.; document any discrepancy between the patient’s and the caregiver’s account of the incident; and photograph of all injuries if present. The health care provider must understand that they are responsible for knowing the laws in their particular province that relate to their practice. Most Canadian jurisdictions have some form of mandatory reporting. For example, in Ontario, Alberta and Manitoba any form of abuse in an institution must be reported to an outside authority. In addition, the organization in which they work should have appropriate policies and procedures to guide the health care profession when confronted with suspected abuse.

This knowledge is essential in avoiding improper or incorrect responses to the detection and reporting of abuse. In elder abuse three key ethical and legal issues may come into conflict are the legal duty to report certain suspected abuse to law enforcement; the victim’s right to self determination versus protection and safety; and when intervening , selecting the least restrictive alternative versus protection and safety. The protection of persons in Care Act came into effect on January 5, 1998. ……………………It contains a mandatory requirement to report suspected or actual abuse of adults in care regardless of other laws protecting confidentiality (Ross-Kerr, 1998).

Abuse Prevention Strategies

A preliminary point for addressing elder abuse is recognition of the fact that every person has the right to be treated with respect and dignity. It is a fundamental human right and no one deserves to be abused. Most elder abuse takes place at the elder’s residence and not in nursing facilities. Abused elders may have been threatened with placement in a nursing home by their family members, they may fear abandonment, and they may even feel ashamed that a family member is abusing them.

Despite the fact abuse in institutional settings is dealt within a variety of ways across Canada. Gradually, a growing number of health care facilities have focused their efforts on prevention and education (training staff to identify and recognize abuse; and training staff so they have proper skills to avoid becoming abusive). Educating health care workers about the causes and types of abuse can also be an effective abuse prevention strategy. Nurses also need to seek alternative interventions when residents object to specific procedures. For example, the staff can offer the resident a bath instead of a shower, or offer to help them bathe at a different time (Lueckenotte, 2000; Sudbury Elder Abuse Committee, 2001). This promotes the elderly individuals choice and dignity.

Recommendation for further nursing research

Nurses as highest level of care providers have the best interest of the elders as their focal point while providing loving, appropriate care to enhance their quality of care, their quality of life and their overall all satisfaction in the latter days of their lives. However, while providing safe and competent care; they are also obligated to provide an ethical care. Although there are gaps in knowledge with respect to the clinical manifestations and treatment of elder abuse, they should not prevent clinicians from taking an active role in identification and management. Elder abuse directly affects quality of life, and removal of a patient from an abusive situation is one of the most gratifying experiences for nurses and other healthcare professionals. Consequently, nurses need to be vigilant in identifying abuse through comprehensive assessment, report it when it occurs and plan an intervention to prevent abuse.

Conclusion

Although elder abuse is on the rise, abused elderly who are victims are often reluctant to report abuse. Consequently, the incidence of elder abuse is likely to be under-reported, underestimated, and not well documented. Therefore, it is crucial for health care providers to recognize the signs and symptoms of the various types of abuse and intervene promptly in an appropriate manner. Besides, all individuals regardless of their social status, race and age deserve to be treated with respect and dignity. The elderly clients are no exceptions.

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