Ethical Considerations in Senior Living
As the population ages and more individuals are moving into senior living communities, care providers are encountering an uptick of ethical considerations and issues. In some cases, this is related to varying levels of cognition and cognitive decline, while in others this is related to bullying behavior, and in still others this stems from care environments where staff are asked to "do more with less." This article will give a glimpse into the ethical principles that guide decisions and some of the ethical issues practitioners face in today's healthcare environment. There are no straightforward answers, just issues to ponder.
Very simply stated, ethics guide the determination of right and wrong in moral life. One's moral life extends into one's professional life and choices are dependent upon contextual consideration. The basic ethical principles in healthcare include:
- Autonomy - the right to make choices and decisions about one's own course of action; the right to self-determination
- Nonmaleficence - reminds us that if we cannot help patients, at the very least we owe a duty not to harm them or make them worse than they were before they sought help.
- Beneficence - the duty to prevent harm to others, remove harm from others and to promote good.
- Justice - fair distribution of burdens and benefits in society and giving individuals their fair due
In healthcare, ethical challenges include all types of ethical issues, whereas an ethical dilemma is a special type of ethical challenge where one has to choose between different options with no discernible good choice. An ethical dilemma in healthcare is a situation where an individual must decide between competing values and understand that no matter what choice they make, there are consequences. In senior living, ethical challenges can be divided in two major groups: 'everyday ethical issues' such as informed consent, autonomy, refusal of medication or food and offensive behavior, and 'big ethical issues' which mainly are about end-of-life care and decision-making. Interestingly enough, it is the everyday ethical issues that build up and often go neglected that tend to create the most stress for clinicians.
So, what are the common issues we face in healthcare and how do these ethical principles play a part? One of the most significant issues providers encounter is fraud and abuse as these relate to insurance billing. Fraud occurs when an individual makes misrepresentations or lies in order to induce an entity or an individual to do something or refrain from doing something. In the context of billing, this may include billing for services never provided, billing for more services than were actually provided, and billing for non-covered services as covered services. While not a basic principle of ethics, this situation violates a closely related principle - that of veracity. While there are many possible reasons for a clinician to commit fraud, none of them justifies the action or the violation of veracity and any case of fraud must be dealt with immediately.
Healthcare providers face issues related to autonomy regularly. This could relate to something as simple as a resident choosing what he or she would like to eat, to when and how they would like to manage their hygiene, to what activities they would like to attend. More complex issues arise when a resident intends to enter a relationship with another resident (possibly where one is married or has dementia), when a resident chooses to spend funds in a certain way (and is thwarted by a POA or relative), when they are coerced into taking medications or attending therapy sessions (when they would prefer not to), or when a well-meaning family or staff member makes a decision for the person (when the person is not cognitively impaired). There are no easy answers for these situations, but each one violates a person's autonomy to make decisions. Further, many of these demonstrate paternalism. When individuals act in a paternalistic manner, they substitute their own beliefs, opinions and judgments for the patient's judgment. They may act without informed consent or against the patient's wishes under the guise of a desire to benefit the patient. Usually, people justify paternalistic actions by claiming they acted in the person's best interests, and this often occurs when the patient's wishes and the family or health provider's wishes differ. It is important to remember that in practically all cases, our duty and accountability is to the patient, not the family.
Elder abuse is a growing geriatric concern, and clear evidence of the prevalence and scope of the problem is not available. An informed and enlightened social policy requires increasing our awareness to its extent and magnitude. We must look far beyond adult protective services records and examine financial, medical, social, and long-term care areas for possible difficulties and solutions. Elder abuse represents a health and social system breakdown; with the demographic changes in our society, this issue is becoming more compelling with each census and is likely to expand in volume and complexity. In senior living, abuse can take many forms including physical, emotional, financial, sexual, and neglect. Each of these is reportable under the Elder Justice Act and each is a violation of the ethical principles of nonmaleficence and beneficence.
Confidentiality is a growing concern as well. The internet is an electronic billboard! You may expect electronic messages to remain private, but once you send it or post it you've lost all control over it. Deleting an electronic message does not make it invisible or undiscoverable! In addition, text messaging, social media, email and voice mail all present challenges for patient confidentiality, even if the facility has a 'HIPAA-compliant' network. We have an ethical duty to protect patient information and staff should make all efforts toward this goal.
There are many more issues than these, namely end-of-life decisions, health literacy and decision making, incompetence among peers, distribution of resources, and more. Each practitioner has a duty and moral obligation to act in a professional and ethical manner. The way to do this is to stay plugged in to one's professional association, read your code of ethics and licensure laws, ask questions, and bounce ideas off a mentor (while remaining HIPAA compliant). In addition, utilize the ethics committee in your facility. Bring issues (even the small ones) to the committee to discuss and resolve, making sure to include residents in the committee. If you do not have one, consider creating one. Above all things, address situations as they arise. Not only will you have more options for resolution, but you will prevent some of the negative consequences of ethical challenges like stress, burnout, loss of employment, and possibly legal ramifications.
To summarize, just do the right thing! Do the right thing because it's the right thing to do. Don't do wrong things; avoid them because they are wrong. As a trusted mentor once said to me, if it doesn't feel right in your gut, then it probably isn't. The end, in this case, does not justify the means.
About the author:
Dr. Kathleen Weissberg in her 30+ years of practice, has worked in rehabilitation and long-term care as an executive, researcher and educator. She has established numerous programs in nursing facilities; authored peer-reviewed publications on topics such as low vision, dementia quality care, and wellness; and has spoken at numerous conferences both nationally and internationally. She provides continuing education support to over 30,000 therapists, nurses, and administrators nationwide as National Director of Education for Select Rehabilitation. She is a Certified Dementia Care Practitioner, Certified Montessori Dementia Care Practitioner, Certified Fall Prevention Specialist, and a Certified Geriatric Care Practitioner. She serves as the Region 1 Director for the American Occupational Therapy Association Political Action Committee and is an adjunct professor at Gannon University in Erie, PA.
