Gerontology Ethical and Legal Issues

MSNG 502 – INTRODUCTION TO GERONTOLOGY
FINAL Requirement

A. Ethical and Legal Issues Affecting Elderly

Loss of rights, victimization, and other grave problems face the person who has made no plans for personal and property management in the event of disability or death. The advice and services of a competent attorney regarding financial and personal issues can preserve future autonomy and self-determination. The nurse as an advocate can encourage the older person to prepare advance directives for future decision making in the event of incapacitation.

A power of attorney is a legal agreement that authorizes a designated person to act in specific, outlined circumstances on behalf of the signer. This is a form of voluntary guardianship, permission for which is freely granted when the older person is competent. Unless stated otherwise, a power of attorney is invalidated on the incapacity of the signer. A durable power of attorney is a similar agreement that continues even if the older person is disabled or incapacitated.

A trust is another option that the competent older person can consider. In a trust, the person designates someone to manage his or her property, stipulates how and under what circumstances the property will be managed, and designates a beneficiary. If incompetency or disability occurs, management of the property is undertaken according to the person’s wishes. If no advance arrangement has been made, and the older person appears unable to make decisions, anyone can petition the court for a competency hearing. If the court rules that the person is incompetent, the judge will appoint a guardian – a third party who is given powers by the court to assume responsibility for making financial or personal decisions for that person.

There are two kinds of guardians: guardian of the person and guardian of the estate. Because such a court action strips the civil liberties and constitutional right from the older person, a potential for great harm exists. Safeguards include the following: 1. The older person must be given notice. 2. He or she must be given an opportunity to be legally represented. 3. Medical testimony can be cross-examined. A less restrictive.
A less restrictive form of guardianship, called limited guardianship, transfers to the appointed guardian only those powers or duties that the older person cannot exercise. Although this alternative is not widely used, it remains an option.

An advance directive is a formal, legally endorsed document that provides instructions for care (living will) or names a proxy decision maker (durable power of attorney) and is to be implemented in the event of the signer’s future decision-making incapacity. This written document must be signed by the person and by two witnesses; a copy should be given to the physician and incorporated into the medical record. The person must understand that this document is not meant to be used only when certain (or all) types of medical treatment are withheld; rather, it allows for detailed description of all health care preferences, including full use of all available medical interventions. The health care proxy has the authority to interpret the patient’s wishes on the basis of the medical circumstances of the situation and is not restricted to deciding only whether life-sustaining treatment can be withdrawn or withheld.

In 1990, the Patient Self-Determination Act (PSDA), a federally mandated law, was enacted to require patient education about advance directives at the time of hospital admission, along with documentation of this education. The PSDA is also mandated in nursing homes to enhance resident autonomy by increasing involvement in health care decision making. A growing body of research indicates that nursing homes implement the PSDA more vigorously than hospitals do. In both settings, however, the documentation and placement of advance directives in the medical record varies considerably from facility to facility, as does the education of patients about advance directives. Processes for fulfilling the requirements of the law are continuously being revised in many facilities to promote compliance. The PSDA provides no guidelines regarding how often the advance directives of nursing home residents should be reviewed. Continuing quality improvement programs that establish guidelines for review are more likely to exist in nursing homes in which ethics committees are present. The nurse can play a vital role in advocating for the patient when the patient or a family is unable to do so.

MISTREATMENT OF THE OLDER ADULT

Mistreatment of the elderly (also referred to as elder abuse) is a serious and ever-increasing problem and disturbing trend. It is estimated that annually 1 million or more older Americans are victims of some form of abuse. There are many forms of elder abuse, including: 1. Physical abuse – willful infliction of injury 2. Neglect – withholding goods or services (such as food, attention) to the detriment of the elder’s physical or mental health 3. Psychological abuse – withholding affection or imposing social isolation 4. Exploitation – dishonest or inappropriate use of the older person’s property, money, or other resources

* Signs of Physical Mistreatment in the Elderly:
> Contusions > Freezing
> Lacerations > Oversedation
> Abrasions > Poor hygiene
> Fractures > Malnutrition
> Sprains > Dehydration
> Dislocations > Scratches
> Burns > Welts
> Bruising > Depression
> Malnutrition > Sexual Molestation
> Decubiti > Over- or undermedication
> Human bite marks > Head and face injuries
> Misuse of medications
> Untreated but previously treated conditions
> Erratic hair loss (especially orbital fracture, hair pulling, black eyes, broken teeth)

Nurses in the home, clinic, hospital emergency department, and long-term care setting are often the first to identify signs of mistreatment in elderly people; see the accompanying display on signs of physical abuse. Abused elderly may either cling to or act in a very guarded manner toward the abuser. Another indicator of possible abuse is vague explanations offered for the cause of the injuries. Psychosocial indicators of abuse may be anger and rage, depression, anxiety, and conflictual interactions between the older adult and the abuser.
When assessing for mistreatment, the nurse must be nonjudgmental and avoid any signs of disapproval that may evoke further feelings of anger and shame in the older client. A private setting should be used for interviewing to promote sharing; also, if the older victim thinks the perpetrator is able to hear the interview, the victim may withhold information or refuse to talk. It is essential that the interview findings be documented in an accurate and unbiased manner.
Nursing interventions for the abused elder are primary, secondary, and tertiary. Primary intervention strategies emphasize prevention. Secondary interventions consist of early identification and prompt treatment to minimize the long-term effects of the abuse. Tertiary interventions occur after the abuse and promote recovery and rehabilitation. Tertiary interventions are restorative in nature.

B. Common Problems of Nurses in Dealing with Geriatric Patients

Here are some common elderly behaviors encountered by nurses and caregivers:

* Rage, Anger, Yelling
Age and illness can intensify longstanding personality traits in some unpleasant ways: An irritable person may become enraged, an impatient person demanding and impossible to please. Unfortunately, the person taking care of the elderly patient is often the target.

What to do:
Try to identify the cause of the anger. In most elderly individuals, behaviors are a symptom of distress.

The aging process in and of itself sometimes brings about anger, as seniors vent frustration about getting old, having chronic pain, losing friends, having memory issues, being incontinent – all of the undignified things that can happen to us as we age.

* Abuse
Sometimes, elderly patients turn on the person that is trying to take care of them and the result is abuse to the nurse or caregiver. They don 't consciously abuse them but they are frustrated and need to vent their frustration about getting old, having chronic pain, losing a spouse and friends, having memory issues, being incontinent, etc.
What to do:
Try talking to them about how the abusive behavior makes you feel. If the abuse is verbal or emotional, making them realize all that you do for them, by not doing it for awhile, may drive home the point that they better be nicer to you, or you will leave. Finding a little respite for yourself by getting help will allow your patient to gain a new appreciation for all you do.

* Resistance to Showers and Hygiene
The issue of elders who were once reasonably clean refusing to take showers, wear fresh clothes and take care of personal hygiene is one that is far more common than most people think - and it 's very frustrating for nurses and caregivers.

Sometimes the issue is depression. Another factor is control. As people age, they lose more and more control over their lives. But one thing they generally can control is dressing and showers. The more they are nagged, the more they resist.

A decreased sense of sight and smell may be causing the problem. What your nose picks up as old sweat, they don 't even notice. Or, memory could be to blame. The days go by. They aren 't marked with tons of activities so they lose track of time and don 't realize how long it 's been since they showered.

Another big issue can be fear or discomfort: Fear of slipping in the tub; or embarrassment about asking for help.

What to do:
The first step is to determine why they have stopped bathing. If they have lost their sense of smell, consult the doctor. Medications they’re taking, or some unrelated disorder may be at fault for a loss of smell.

* Swearing, Offensive Language and Inappropriate Comments
There are elderly patients who used to be mild-mannered, proper, and would never utter a four-letter word suddenly cursing at the nurses or caregiver and calling them insulting names. When it happens in public, it 's embarrassing; when it happens in private it 's hurtful.

What to do:
When the behavior is out-of-character for an elderly, the start of Alzheimer 's or dementia is a likely cause. When a swearing tirade sets in, use distraction. Diverting the elderly patient 's attention is a simple, but effective technique. Once their mind is redirected, the swearing fit may end.

Also, try bringing up happy times from the old days. Like all people, elderly love to reminisce about their lives "back in the day." Using their long-term memory skills, the elderly patient will likely forget about whatever it is in the present that set them off.

* Paranoia and Hallucinations
Paranoia and hallucinations in the elderly can take many forms, from accusing family members of stealing, seeing people who aren 't there or believing someone is trying to murder them.

What to do:
Sometimes hallucinations and delusions in the elderly are a sign of a physical illness. Keep track of what the elderly is experiencing and discuss it with the doctor. It could also be a side-effect of a medication your elderly patient is taking.

Oftentimes, paranoia and hallucinations are associated with Alzheimer 's disease or dementia. When this is the case, caregiving experts seem to agree: when faced with paranoia or hallucinations, the best thing to do is just relax and go with the flow. More often than not, trying to "talk them out" of a delusion won 't work. Validation is a good coping technique, because what the elder is seeing, hearing or experiencing is very real to them. Convincing them otherwise is fruitless.

* Hoarding
When an elderly patient hoards (acquiring and failing to throw out a large number of items), once again the onset of Alzheimer 's or dementia could be at fault. Someone 's pre-Alzheimer 's personality may trigger hoarding behavior at the onset of the disease.

What to do:
You can try to reason, and even talk about items to throw out and give away. Or create a memory box, a place to keep "special things." With extreme hoarders, medication and family counseling could make a big difference in how you cope and manage.

* Other commonly difficult behaviors of elderly includes: * Constant complaining – about everything, including you, no matter how hard you try to help. * Clinging behavior. * Withdrawal from social interaction, and refusal to participate in activities. * Failure or refusal to take needed medications. * Refusing or failing to eat properly. * Forgetting; losing things; confusion; wandering. * Extreme disorganization and cluttered chaos, while refusing help.

What to do: 1. Get a professional diagnosis of the likely cause of the behavior, and treat it. 2. Learn to behave in helpful ways as a nurse or caregiver. 3. Try other non-medication therapies such as regular exercise and physical therapy under a doctor’s supervision; music therapy; pet therapy; talk therapy; introducing inspiring, calming and positive thoughts and meditations; and involving the elderly in daily activities that are absorbing and stimulating to them. 4. Obtaining good medical advice, and second opinions, about potential medications.

References:

Books:
Smeltzer, Suzanne et. al. 2004. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 10th Edition. Maryland, USA: Lippincott Williams and Wilkins
DeLaune, Sue et. al. 2002. Fundamentals of Nursing Standards and Practice. 2nd Edition. Clifton Park, New York, USA: Thomson Learning Inc.

Websites: http://www.helpingyoucare.com/wp-content/uploads/2010/07/Four-Steps-to-Deal-with-Difficult-Elderly-Behavior-by-Editor-HelpingYouCare-V2.pdf http://www.agingcare.com/Articles/strange-obsessions-OCD-elderly-parent-138673.htm

References: Books: Smeltzer, Suzanne et. al. 2004. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 10th Edition. Maryland, USA: Lippincott Williams and Wilkins DeLaune, Sue et. al. 2002. Fundamentals of Nursing Standards and Practice. 2nd Edition. Clifton Park, New York, USA: Thomson Learning Inc. Websites: http://www.helpingyoucare.com/wp-content/uploads/2010/07/Four-Steps-to-Deal-with-Difficult-Elderly-Behavior-by-Editor-HelpingYouCare-V2.pdf http://www.agingcare.com/Articles/strange-obsessions-OCD-elderly-parent-138673.htm