Transcript Document

Medical, Legal, Ethical
Aspects of Geriatrics
Min H. Huang, PT, PhD, NCS
ELDER MISTREATMENT
Reading assignments
• Mosqueda & Dong, 2011 (posted on
Blackboard)
• Yaffe & Tazkarji, 2012 (posted on Blackboard)
• http://www.nlm.nih.gov/medlineplus/ency/patienti
nstructions/000472.htm
• http://www.caringinfo.org/files/public/brochures/E
nd-of-Life_Decisions.pdf
• http://www.cancer.org/acs/groups/cid/documents
/webcontent/003014-pdf.pdf
Learning objectives
• Differentiate between elder abuse, self
neglect, and exploitation
• Identify the risk factors and screening
methods for elder mistreatment
• Describe the signs and acts suggestive of
elder mistreatment
• Take appropriate actions to protect geriatric
clients from mistreatment
Elder mistreatment
• Elder mistreatment typically refers to elder
abuse and self-neglect
• National Research Council (NRC) excluded
self-neglect from the definition of elder
mistreatment:
“Intentional actions that cause harm or create a
serious risk of harm, whether or not intended, to a
vulnerable elder by a caregiver or other person who
stands in a trust relationship to the elder, or failure
by a caregiver to satisfy the elder’s basic needs or
to protect the elder from harm.”
Three components of elder abuse
defined by National Research Council
• Older adults
o 55+ or 65+ y.o. as
defined by law
• (Intentional) Harm
o Psychological
abuse
o Financial abuse
o Physical abuse
o Sexual abuse
o Neglect
• Trust relationship
o Individuals in whom
the older adult
would reasonably
have confidence
o Family members,
close
acquaintances,
professionals, and
paraprofessionals.
Institutional neglect
• Elder abuse is not limited to the home or to a
community encounter, but might occur within
retirement homes, assisted living facilities,
nursing homes, and hospitals
Self-neglect
• The National Center on Elder Abuse
defined self-neglect as
“…. The behavior of an elderly person that
threatens his/her own health and safety. Self
neglect generally manifests itself in an older
person as a refusal or failure to provide
himself/herself with adequate food, water,
clothing, shelter, personal hygiene, medication
(when indicated), and safety precautions.”
Self-neglect vs. elder abuse
• Self-neglect is the MOST COMMON form of
elder mistreatment in clinical settings
• Self-neglect (not unique to seniors) might be
reflective of personal problems that generally
fall OUTSIDE the realm of elder abuse
• Self-neglect is mistreatment caused by self
• Elder abuse refers to mistreatment by others
• State reporting mechanisms often lump selfneglect and elder abuse together
Michigan State Laws: Definition of
Abuse
SOCIAL WELFARE ACT 400.11
• “Abuse” means harm or threatened harm to an
adult's health or welfare caused by another
person. Abuse includes, but is not limited to,
non-accidental physical or mental injury, sexual
abuse, or maltreatment.
• “Adult in need of protective services” or “adult”
means a vulnerable person not less than 18
years of age who is suspected of being or
believed to be abused, neglected, or exploited.
Michigan State Laws: Definition of Neglect
(THE SOCIAL WELFARE ACT 400.11)
“Neglect” means harm to an adult's health or welfare
caused by the inability of the adult to respond to a harmful
situation or by the conduct of a person who assumes
responsibility for a significant aspect of the adult's health or
welfare. The failure to provide adequate food, clothing,
shelter, or medical care. A person shall not be considered
to be abused, neglected, or in need of emergency or
protective services for the sole reason that the person is
receiving or relying upon treatment by spiritual means
through prayer alone in accordance with the tenets and
practices of a recognized church or religious denomination,
and this act shall not require any medical care or treatment
in contravention of the stated or implied objection of that
person.
Michigan State Laws: Definition of
Exploitation and Vulnerability
THE SOCIAL WELFARE ACT 400.11
• “Exploitation” means an action that involves
the misuse of an adult's funds, property, or
personal dignity by another person.
• “Vulnerable” means a condition in which an adult
is unable to protect himself or herself from
abuse, neglect, or exploitation because of a
mental or physical impairment or because of
advanced age.
Most commonly reported elder
mistreatment
1. Self neglect (29%)
2. Caregiver neglect (26%)
3. Financial exploitation (19%)
4. Psychological abuse (12%)
5. Physical abuse (12%)
Cultural Aspects of Elder Abuse
• AA & CA: less likely to view a situation as
abusive & to seek help due to revealing family
shame
• Japanese Americans: silence and avoidance is
an extreme form of punishment and as
devastating as physical abuse
• Latinos: strong family ties and respect for elders
thought to decrease risk of abuse
• Native Americans: exploitation is a cultural
conflict
Risk factors of being a victim of elder
abuse
• Cognitive impairment
• Tendency to be physically or verbally abusive
• Psychological distress
• Frailty
• Physical vulnerabilities
• Need for activities of daily living assistance
• Old age
Risk factors of being a victim of elder
abuse
• Women
• Dependency on the abuser
• Premorbid relationship to the abuser
• A shared living arrangement
• Isolation, lower levels of social network and
support
• Absence of anyone to call on for help
• Lower household income
Factors predispose caregiver to
mistreat elderly
• Family relation
• Substance abuse, e.g. alcoholism, drugs
• Mental illness
• Unemployment
• Caregiver stress
• Financial dependency on the care receiver
• Being male
Risk factors of self-neglect
•
•
•
•
•
•
•
•
Age older than 75 years .
African Americans.
Lower socioeconomic status.
Cognitive impairment , especially the executive
function. Mini-Mental is not very useful in
identifying people at risk of self neglect.
Physical disability .
Psychological distress or depression.
Lower levels of social relations.
Alcoholism.
Prevalence of elder abuse
• 14.1% of non-institutionalized older adults
had experienced physical, psychological, or
sexual abuse; neglect; or financial
exploitation in the past year
www.gao.gov/products/GAO-11-208
• Estimate ranges from 2.2% to 18.4%
• Odds of financial mistreatment
―African Americans > Whites > Latinos
―People without a spouse/partner > People with a
spouse/partner
If you’ve seen 15 or 20 older
people a day, you have probably
met an elder abuse victim
Consequences of elder abuse
• Elder abuse is associated with morbidity and
mortality, especially among vulnerable
populations
• In 2009, federal agencies spent $11.9 million
for all activities related to elder abuse
Assessment of elder abuse:
questions asked by clinician
Abused Elder
Caregiver
• Has anybody hurt
you?
• Are you afraid of
anybody?
• Is anyone taking or
using your money
without your
permission?
• Are your mom’s needs
more than you are
really able to handle?
• Are you worried that
you might hit your
mom?
• Have you hit your
mom?
Assessment of elder abuse
• An elder seems fearful of the caregiver
―conduct a private interview and examination
• Bruises, lacerations, burns, and other injuries
in unusual locations without explanation
• Assess patient’s function and cognition
• Note any inconsistencies between the history
and the physical examination findings
―e.g. a patient with good balance reported “I tripped
over a rug and fell”, with multiple facial bruises, and
circumferential bruises on the upper arm.
Assessment of financial abuse
• An elder who is no longer able to afford basic
items
• An elder who suddenly appear at
appointments with a new friend or caregiver
who seems intrusive or protective (e.g.
reluctant to leave the room)
• Direct reports by the patient that an individual
is taking or mishandling the elder’s money
• Ask: “Is anyone taking or using your money
without your permission?”
Elder Abuse Suspicion Index (EASI)
• Outpatient setting
• Seniors with Mini-Mental score > 24
• 1 or more + responses on #2 to #6 suggest
elder abuse
Abuse assessment actions taken by
clinician
• Inform patient that you are making a report
• Tell patient: “I am concerned about this
situation and want to help. I am going to
call an organization called Adult Protective
Services. They will send someone to see
you at home and assess the situation. We
need to see if there is something we can
do to prevent this from happening again.”
Abuse assessment actions taken by
clinician
• Document injury and related history
• Check patient’s injury for size, location, color
and appearance, tenderness, swelling, and
pattern (if present)
• Note if the patient seems fearful of the
caregiver
• Document patient’s language about any
possible abuse incidents in the patient’s own
words
Documentation of elder abuse
• Include the patient’s and caregiver’s
descriptions of the mechanism of injury
• Use direct quotes when possible (e.g. “my
daughter hit me with a broom handle”).
• Include photographs
• Include a clear, concise description of the
injuries
Assistance
• If health system, may contact social work
―Document your follow-up
―e.g. Spoke with SW, SW will contact state.
Next day: Discussed case with SW, SW
stated she contacted state services
• If private practice, may consult social work
―Document steps taken
Cardinal signs that indicate
self-neglect
• Lack follow-up when they do have a
physician (refuse to go)
• They’ve gotten so sick that they end up in an
ER, it turns out that they haven’t been to a
doctor in 15 or 20 years
• Usually they are disheveled
• They are usually malnourished. . . .
• They have untreated medical conditions even
though they may have prescription
medications
Assessment of self neglect
• Ask how the patient manages his/her daily
lives (Do this for ANY geriatric client!)
―Answers can suggest incipient problems that will
impair the patient’s ability to live independently
• Minor difficulties in ADLs
―May predict future self-neglect in months or years
• Early detection and interventions
―Treat underlying conditions
―Community-based services
―Appropriately involving family or caregivers
From: Elder Abuse and Self-neglect: “I Don't Care Anything About Going to the Doctor, to Be Honest. . . . ”
JAMA. 2011;306(5):532-540. doi:10.1001/jama.2011.1085
CLOX-1 test completed by Mrs O had a score of 8 out of 15, revealing
substantial limitations in executive function.
Date of download: 4/21/2013
Copyright © 2012 American Medical
Association. All rights reserved.
Clinician’s Approach When Selfneglect Is Suspected
APS: adult protective services
Self-neglect: Consideration for
patient’s decision-making capacity
• Does …….. have a right to live like this?
• Under what circumstance do the medical
community and society at-large have a
responsibility to override an adult’s wishes?
• Capacity is often NOT completely gone
• The clinician is forced to make it black or
white for purposes of guiding next steps
• Commonly used screening testing, e.g. Mini
Mental, are inadequate to determine capacity
except at the extremes of the scores
Responsibility of reporting elder abuse
and self-neglect
• Most health care professionals in the United
States are mandated reporters.
• The clinician should tell the patient and
caregiver that a report will be made except in
the unusual circumstance where there is
reasonable concern that reporting might
escalate a violent situation
• Failure to report may lead to legal
consequences ranging from monetary
penalties to jail sentences
What to Report
• All suspected cases or incidents of a
“vulnerable person”
• Vulnerable: “condition in which an adult is
unable to protect self from abuse, neglect
or exploitation because of physical or
mental impairment or advanced age”
J. Blackwood
When to Report
• Immediately
• When person required to report suspects or
has reasonable cause to believe that an adult
has been abused, neglected or exploited
J. Blackwood
How to Report
• Local office of the Family Independence
Agency (FIA) in county where the suspected
occurrence took place
―Genesee County 760-2202
―Locate your local reporting agency
• Adult Protective Services Statewide
―1-800-996-6228
―Verbal and/or written report
J. Blackwood
The Report
• Telephone call
• Report
―Patient name
―Description of the Abuse, Neglect, Exploitation
―Other information that may establish the cause of the
Abuse, Neglect, Exploitation
―Patient age, address, name and address of guardian
or who patient resides with
J. Blackwood
Failure to Report
• Civil fine up to $500.00 per occurrence
• Civil liability for the damages approximately
caused by the failure to report
J. Blackwood
Michigan State Laws
III. PUBLIC HEALTH CODE
a. Mistreatment of Nursing Home
Patients: MCL 333.21771
1. Nursing home employees aware of abuse or
neglect must report to nursing home
administrator and administrator must report to
MDCH
2. Nursing home administrator may not retaliate
against a patient, a patient’s representative, or
an employee who makes a complaint.
Michigan State Laws
IV. SOCIAL WELFARE ACT
a. Reporting of Suspected Abuse of Adults: MCL 400.11a
1. Health care providers, law enforcement, medical examiner
employees and service providers, and employees of agencies
providing health care, educational, social welfare mental
health and other human service must report suspected abuse,
neglect, or exploitation to the FIA.
2. Report of suspected adult abuse made by a physician is not
considered a violation of any legally recognized privileged
communication.
b. Confidentiality of Identity of Reporter MCL 400.11c
1. Identity of person making a report shall be confidential,
subject to persons consent or judicial process.
Reasons why clinicians don’t report
• Lack of confidence in the referral agency
• Professional confidentiality
• Fear of losing rapport with clients
• Fear of litigation
• Lack of awareness about reporting
• Belief in the sanctity of the family
• Desire to avoid possible court involvement
• Someone else will do it
J. Blackwood
CAPACITY, COMPETENCE,
AND INFORMED CONSENT
References
• Tunzi M. Can the Patient Decide? Evaluating
Patient Capacity in Practice. Am Fam
Physician. 2001 Jul 15;64(2):299-308.
• Informed consent. http://www.amaassn.org//ama/pub/physician-resources/legaltopics/patient-physician-relationshiptopics/informed-consent.page
Learning objectives
• Differentiate between capacity and
competency
• Describe the assessment and determination
of a patient’s capacity
• Describe the information communicated with
a patient during the informed consent
process
• Discuss the best practice for providing an
informed consent to a patient
Capacity
• Definition: Clinical determination of a
patient’s ability to make decisions about
treatment interventions or other health care
issues
• Clinicians are called on to make decisions
about patients’ capacity, NOT competency,
which is a legal issue  Competency is
determined by the court.
When to assess a patient’s capacity
• Patients have an abrupt change in mental
status
―may be caused by hypoxia, infection, medication,
metabolic disturbances, an acute neurologic or
psychiatric process, or other medical problem
• Patients refuse recommended treatment
―when they are not willing to discuss the refusal,
when the reasons for the refusal are not clear or
when the refusal is based on misinformation or
irrational biases
When to assess a patient’s capacity
• Patients consent to particularly risky or
invasive treatment too hastily and without
careful consideration of the risks and benefits
• Patients have a known risk factor for impaired
decision-making
―e.g. a chronic neurologic or psychiatric condition,
a significant cultural or language barrier, an
education level concern, an acknowledged fear or
discomfort with institutional health care settings,
or adults older than 85 years
How to assess a patient’s capacity
• Directed clinical interview
―History from therapists or caregivers
―Physical assessment
―Laboratory evaluation and other tests
―Possibly neuroimaging studies
―A general mental status examination
Determination of a patient’s capacity
• Patients has decision making capacity if
they
―Understand their health condition
―Consider benefits, burdens, risks
―Weigh the consequences of treatment against
their preferences and values
―Reach a decision that is consistent over time
―Communicate that decision to others
Determination of a patient’s capacity
• Whether a patient has medical decisionmaking capacity depends on whether the
clinician believes that the patient is free of
significant psychopathologic-impaired
thinking and possesses sufficient abilities
to make the specific decision in question
Determination of a patient’s capacity
• The lack of any one ability does NOT mean
that a patient lacks the overall ability to make
a decision
―e.g. patients with limited education, with
diverse cultural backgrounds or with minimal
prior experience in a medical setting may not
completely understand all the alternatives to,
or all the major risks of, a proposed treatment.
However, they may still have enough
understanding overall to make their own
decisions.
Capacity thresholds
• Capacity depends on a sliding scale
threshold that is determined based on the
patient’s decision, and the specific risks and
benefits of the proposed treatment.
―STEP 1: CASE SPECIFICS
A. What is the risk-benefit analysis of the medical
care option recommended to the patient?
B. What is the patient decision? Consent or Refusal
―STEP 2: THRESHOLD DETERMINATION
o Risk benefit analysis, +/- patient consent
Capacity thresholds according to patient decision
and risk-benefit analysis of care options
Capacity ǂ Competency
• Competency
―Judgments that are NOT made by physicians but by
the courts
―The court’s legal “determination of competency”
usually agrees with the physician’s overall
“assessment of capacity”
―A legal determination of incapacity is generally limited
to specified rights, whereas incompetency is (legally)
associated with a loss of legal rights
• Both legally and ethically, Western culture
favors patient autonomy
Competence
• Definition: A legal designation that
recognizes that persons beyond a certain age
generally have the cognitive ability to
negotiate certain legal tasks, such as
entering into a contract or making a will.
• Usually occurs at age 18
J. Blackwood
Competence
• Prior to the 1990’s a person could be deemed
incompetent by virtue of belonging to a
particular category
―Elderly
―Mentally ill
―Physical addiction
• Court deems a guardian
J. Blackwood
Informed consent
• A process of communication between a
patient and clinicians that results in the
patient's authorization or agreement to
undergo a specific intervention
• A capable patient’s legally binding to a
medical decision
• More than simply getting a patient to sign a
written consent form
Information discussed during informed
consent process
• Clinicians should discuss with the patient on:
―The patient's diagnosis, if known
―The nature and purpose of a proposed treatment or
procedure
―The risks and benefits of a proposed treatment or
procedure and the alternatives (regardless of cost or
insurance)
―The risks and benefits of not receiving or undergoing
a treatment or procedure
• Patient should have an opportunity to ask
questions
Informed Consent
• The process of disclosing relevant medical
information is an ethical duty that requires the
physician to tailor disclosures to each
individual patient
• Allows physician to withhold information
―If believe the patient would suffer from direct and
immediate harm as a result of the disclosure
• The right to make informed decisions does
not mean the patient has the right to demand
medically unnecessary or inappropriate care
Best practice for providing the
informed consent
• Document the consent process on the
medical record to protect yourself in litigation
• A comprehensive listing will be difficult for the
patient to understand and any omission from
the list will likely be presumed undisclosed.
• If you are using a form that contains a list,
consider, with your attorney, inserting
language indicating that the list is not
exclusive (such as "included, but not limited
to") before the list begins.
How to Provide Informed Consent
• Allow sufficient time to respond or discuss
• Find out the reason for the refusal
• Talk with patient alone
• Honor the use of family decision, however,
keep checking with the patient
J. Blackwood
Situations where informed consent
does not apply
• Individuals who make decisions must be
legally recognized as adults in the state
where treatment is given
• In an emergency, if a person is unconscious
and in danger of death or other serious
outcome if medical care is not given right
away
• Decision made by the parent, guardian, or an
incompetent adult may be challenged by the
doctor or facility, and then the court
ADVANCED DIRECTIVES, DNR,
AND OTHER ETHICAL ISSUES
References
• Advance Directives and Do Not Resuscitate
Orders
familydoctor.org/familydoctor/en/healthcaremanagement/end-of-life-issues/advancedirectives-and-do-not-resuscitate-orders.html
• End of life issues
www.nlm.nih.gov/medlineplus/endoflifeissues
.html
• What Is Palliative Care?
http://www.getpalliativecare.org/whatis/
Learning objectives
• Describe different types of documents in the
Advanced Directives, including Living Wills,
Medical or health care power of attorney
(POA), and Do Not Resuscitate (DNR)
order.
Advanced Directives (AD)
• Definition: Documents written in advance of
serious illness that state your choices for
health care, or name someone to make those
choices, if you become unable to make
decisions.
• The Patient Self-Determination Act of 1990
requires hospitals to inform their patients
about advance directives
Advanced Directives (AD) include:
• Living will
―a legal document specifies the types of medical
treatments and life-sustaining measures desired
• Medical or health care power of attorney (POA)
―a legal document that designates an individual
(health care agent or proxy) to make medical
decisions
• Do not resuscitate (DNR) order
―a request to not have CPR
Living Wills
• A written, legal document that describes the
types of medical or life-sustaining treatments
you would want if you were seriously ill
―e.g. mechanical breathing (respiration and
ventilation), tube feeding or resuscitation
• In some states, living wills may be called
health care declarations or health care
directives
• A living will does NOT let you select someone
to make decisions for you
Medical or health care power of
attorney (POA)
• A legal document that designates an
individual, i.e. your health care agent or
proxy, to make medical decisions for you in
the event that you're unable to do so
• It is different from a power of attorney
authorizing someone to make financial
transactions for you
Do not resuscitate (DNR) order
• A request to not have cardiopulmonary
resuscitation (CPR) if your heart stops or if
you stop breathing.
• Advance directives do NOT have to include a
DNR order, and you don't have to have an
advance directive to have a DNR order.
• Your doctor can put a DNR order in your
medical chart.
End of life
• From 1994 to 2012, over 126 legislative
proposals in 25 states to legalize assisted
suicide and euthanasia were defeated
• (Non-voluntary) Euthanasia (mercy killing)
―Illegal in all countries
• Involuntary euthanasia
―Murders
• Assisted Suicide (voluntary euthanasia)
―Legal in Oregon and Washington
End of Life: Palliation (palliative care)
• Specialized medical care for people with
serious illnesses
• Provide patients with relief from the
symptoms, pain, shortness of breath, fatigue,
and stress of a serious illness, regardless of
the diagnosis
• The goal is to improve quality of life for both
the patient and the family
• Provided at home or at hospice
What are they?
When are they appropriate to use?
What are the potential risks?
RESTRAINTS
Medical Restraints
• Physical
―Belts, bands
―Vests
―Lapboards, Siderails
―Sheets
• Chemical
―Medications
• Environmental
―Alarms
J. Blackwood
Rationale for Using Restraints
• Keep pt from pulling medical equipment
• Keep pt from moving during procedures
• Keep pt from falling – OOB, walking
• Keep pt from sliding out of chair
J. Blackwood
Risks of Restraint Use
• Elimination problems
• Injury
―Stress: Pulling against restraint
―Constriction: Restraint wraps around pt
• Immobility
―Pulmonary, Skin, DVT, Weakness
• Depression
• Death
J. Blackwood
Types of Restraints
• Wrist/Ankle Strap – Soft or leather
• Protective Mitt
• Posey Vest
• Waist Restraint
• Sedatives
• Bed or chair alarms
J. Blackwood
The Law & Restraints:
• Need a physician order
• New order every 24 hours
• Needs to be very specific
• Medical need
• Patient may refuse
• Must offer mobility, bathroom, water every 2
hrs
J. Blackwood
Other Issues Related to Restraints
• Discuss with family
• Off while family present (potentially)
• May require informed consent of guardian
• Never to be used as a form of discipline
• Pt must be able to remove at will
• Resident may refuse the restraint
• No controlled study has indicated restraints
reduce falls or fall preventable injuries.
J. Blackwood