Ethical Concerns in Addressing Elder Abuse - Respecting Autonomy and Self-Determination while Providing Protection December 2004

Ethical challenges confront professionals and volunteers in the aging fields as they attempt to assist abused and neglected elders. To ignore the competent elder's right to self-determination is to demonstrate ageism and paternalism, and constitutes a violation of the elder's civil rights. Failing to intervene, however, may result in endangering the individual, and at times, the community. The process for determining competence is equally challenging for health care and legal systems professionals. Attempting to balance the need for autonomy with the need to protect an older individual from abuse, neglect and self-neglect is at the core of adult protective services decision-making as well as legal representation.

The following references illustrate some ethical themes that arise when addressing elder abuse and neglect. Most of these reference materials may be obtained through your local university and community libraries or interlibrary loan services. Some must be ordered directly through the publisher or production company. When available, contact and pricing information is included with the abstract. Increasingly, many resources are available online, and the web addresses are also included.* If you have difficulty obtaining any of these materials, please contact the CANE office for assistance.

CANE is a service of the National Center on Elder Abuse (NCEA) which is supported by a grant from the Administration on Aging.

(* If an address provided is no longer accurate, we recommend using a generic search engine, such as Google, to find a current link. If you cannot locate the online publication, contact the CANE offices for assistance.)

2004

1. P5582-25
American Psychological Association (APA)
Guidelines for Psychological Practice with Older Adults
American Psychologist; Vol. 59 (4), 236-260; May-June 2004.
Journal article (scholarship)
Due to shifting demographics, the need for psychological services for older Americans has increased significantly. A recent survey of psychologists throughout the country indicates that while 69 per cent of participants provide therapy for older clients, only 30 per cent had any graduate coursework in gerontological issues, and less than 20 per cent had any supervised internship in this area. Seventy per cent of the respondents indicated that they wanted training in geropsychology. This paper publishes the guidelines developed by the American Psychological Association (APA) for clinicians treating older adults. It is designed to allow practitioners to evaluate their qualifications to assist senior clients, and to assist clinicians in obtaining needed training. The 20 guidelines are categorized into the following topics: attitudes; general knowledge about adult development, aging and older adults; clinical issues; assessment; intervention, consultation, and other provisions; and education. Ageist stereotypes and counter transference that interfere with clinical objectivity are addressed, along with the need to understand the impact of collective social and psychological influences present during the client's lifetime. Equally important is the need for clinicians to stay informed about health-related aspects of aging, including physical, psychological, cognitive and behavioral changes that may typically accompany the aging process versus those that are indicators of illness. Pharmacological issues area also described. A great deal of attention is given to the special ethical and legal issues that often accompany the treatment of older clients, such as autonomy, competency, and confidentiality.

2. P5646-26
Bergeron, L.
Elder Abuse: Clinical Assessment and Obligation to Report (Chapter 7 from Health Consequences of Abuse in the Family)
American Psychological Association; Washington, D.C.; 2004.
Book chapter (scholarship)
Research suggests that elder abuse contributes to such psychological and psychiatric conditions as depression, post-traumatic stress, learned helplessness and alienation. According to the author, the purpose of this chapter is to address the role of the mental health professional in the clinical assessment, reporting and intervention of familial domestic elder abuse (noninstitutional). When reporting suspected abuse, counselors, psychologists and others are urged to inform the client of this, while emphasizing consideration for the client's safety. Professionals are also reminded that it is their legal and/or ethical obligation to report suspected abuse, not to verify the suspected mistreatment. Practical guidelines (including specific questions) for assessing the situation and reporting are outlined. Physical and psychological risk factors are summarized, along with theoretical models of elder abuse. Case examples illustrate various scenarios of suspected elder mistreatment. (Neither self-neglect nor the mistreatment of individuals with developmental or other disabilities under age 60 are the subject of this chapter.)

3. P5675-4
Nusbaum, N.
Safety versus Autonomy: Dilemmas and Strategies in Protection of Vulnerable Community-Dwelling Elderly
Annals of Long-Term Care; Vol. 12 (5), 50-53; May 2004.
Journal article (scholarship)
The author of this commentary suggests that the current laws addressing elder abuse are not effective in addressing the ethical challenge of balancing autonomy with safety of vulnerable elders living in the community. The author criticizes aspects of the criminalization of elder abuse that focus more heavily on determining the perpetrator's motives and culpability rather than taking a broader, preventative approach to protecting the elder. Issues surrounding self-neglect and self-destructive behaviors (such as refusing Meals on Wheels or other supportive services) are considered along with issues that impact the safety of others as well as the elder (such as driving when marginally impaired, or possessing a firearm). He proposes that alternatives to moderate the risk to the individual, rather than "black or white" solutions (such as restricted licenses versus revoking licenses, enrollment in supportive community services, and placements in environments less restrictive than nursing homes) should be considered in an effort to preserve autonomy.


2003

4. P5490-5
Abramson, B.
Ethical Considerations in Potential Elder Abuse Cases
Naela Quarterly - The Journal of the National Academy of Elder Law Attorneys
Vol. 16 (4), 15-19; Fall 2003.
(Note: This is an adaptation of a previously published article, available online at http://www.wisbar.org/wislawmag/2000/09/abram.html .) In this article, the "4 Cs" of ethical considerations are reviewed and illustrated: client identification, conflicts of interest, communication, and competency. Scenarios that highlight these issues are possible violation of fiduciary duty by an agent, perceived abuse between spouses, physical abuse by an adult child, financial abuse occurring within a second marriage, and threatened criminal activity.

5. P5125-10
Bergeron, L.R. & Gray, B.
Ethical Dilemmas of Reporting Suspected Elder Abuse
Social Work; Vol. 48 (1), 96-105; 2003.
In this article, the role of caregiver support group facilitator is considered in light of the need to report suspected elder abuse or neglect. Case studies are used to illustrate various ethical dilemmas that may arise as social workers and counselors facilitate group sessions. Balancing the right to confidentiality with the benefit of the care recipient as well as that of the group is discussed. Questions raised regarding caregiver abuse by the care recipient add to the complexity. The authors advise the facilitators to become familiar with both the reporting laws for the area and the elder abuse literature. In addition, participants should be made aware, in advance, of exceptions to confidentiality. Samples of confidentiality statements are provided.

6. P5311-51
Dessin, C.
Financial Abuse of the Elderly: Is the Solution a Problem?
McGeorge Law Review; Vol. 34; Winter 2003.
Journal article (legal scholarship)
This article provides a comprehensive discussion and examples of the "often vague" definition of financial abuse in existing state legislation. Statutes are often vague in order to allow for flexibility in addressing financial exploitation, but this also weakens effectiveness in terms of prosecution. Many laws presume that an abusive act benefits the perpetrator and involves lack of consent. The simplistic assumption that one's assets should always be retained for one's own benefit is considered as it negates the autonomy of many elders who, out of a sense of duty or generosity, may wish to give to others. The complexities of identifying exploitation involving incompetent individuals and the difficulty of monitoring guardianship issues are also examined. The benefits and weaknesses of voluntary arrangements, such as powers of attorney and trusts are also considered. The author argues that legally defining financial abuse and exploitation in terms of age is an example of "new ageism." She proposes an alternative without ageist stereotyping.

7. P5731-9
Healy, T.
Ethical Decision Making: Pressure and Uncertainty as Complicating Factors
Health & Social Work; Vol. 28 (4), 293-301; November 2003.
Journal article (research)
This study explores the ethical tensions that impact the home health care social worker in evaluating the decision making capacity of individuals with some degree of cognitive limitations. In particular, the tension between balancing the needs for autonomy and beneficence are considered. Seventeen home health care social workers who primarily serve Medicare clients were asked to describe three clients with varying degrees of cognitive impairment, and the types of clinical issues related to each client's care and case management. Three areas were identified as significantly impacting the participant's assessment of decisional capacity: clinical uncertainty; mental health problems; pressure from other professionals; and ambiguity regarding the cause of poor decisional capacity. Ethical tension was strongest when social workers experienced both clinical uncertainty and pressure from other professionals; when the practitioner felt certain that her evaluation was accurate, she was more inclined to take a stronger position. The interplay between health and mental health issues supports the need for integrated health and mental health services.

8. P5342-62
Karp, N. & Wood, E. for the American Bar Association Commission on Law and Aging
Incapacitated and Alone: Health Care Decision-Making for the Unbefriended Elderly
American Bar Association Commission on Law and Aging, with funding by Fan Fox and Leslie R. Samuels Foundation, in collaboration with the Samuel Sadin Institute on Law, Brookdale Center on Aging; Washington, D.C.; July 2003.
Report
This report presents the findings of a study of one of the most vulnerable groups of patients in society, the decisionally-incapacitated unbefriended elderly. This patient is defined as one who does not have the capacity to make decisions regarding his or her treatment, who has not executed an advance directive regarding the treatment at hand, and has no legally authorized surrogate or family or friends to assist in the decision-making process. Since the legal process in most states to address these patients is insufficient, such patients are subjected to "over-treatment, under-treatment, or treatment that does not reflect their values or best address their well-being." The purpose of this research was to identify the current state of law addressing this issue and to make recommendations for developing practical procedures to assist these patients and guide professionals charged with providing health care. Research methods include statutory and literature surveys, surveys of target groups, in-depth interviews, site visits and focus groups, and an interdisciplinary symposium and state strategy session. Currently, four legal approaches to addressing the decision-making needs of the unbefriended elder exist: statutory authorization for health care decisions; laws that authorize standing committees of trained volunteers to act as surrogates when the needs arise; public guardianship for health and financial decision-making; and a court process for seeking consent or authorization of a surrogate. When states do not have such a process, health care providers are often on their own to determine the best course of treatment. The report presents policy recommendations, including the need for procedures in long-term care facilities to investigate and record resident values and preferences, the improvement and enhancement of the health care providers' assessment of decisional capacity, and the development of state and local temporary medical treatment guardianship programs. (Note: To order, visit the American Bar Association Commission on Law and Aging web site at http://www.abanet.org/aging/publications/publicationslistorder.shtml, or contact the ABA at 202/662-8690. Price: $25.00.)

9. P5665-41        
Kohl, T.
Comment: Watching Out for Grandma: Video Cameras in Nursing Homes May Help to Eliminate Abuse
Fordham Urban Law Journal; Vol. 30; September 2003.
Journal article (legal scholarship)
This legal comment presents arguments both for and against the proposal to grant nursing home residents the right to install video cameras as a means of preventing abuse. Part I presents a discussion of the ineffectiveness of current nursing home regulations, mainly due to lack of enforcement. Privacy issues are examined in Part II, such as the complexities of distinguishing between public, private and semi-private zones within facilities, and the difficulty of obtaining consent for video taping from incapacitated residents. Privacy rights of roommates, employees, visitors and the nursing home institution are considered. The discussion also considers how the Federal Wire Tap Act may apply to this updated technology. Part III addresses the costs associated with video surveillance. Inevitably, residents and/or their families would likely absorb the cost, directly or indirectly. Additionally, opponents of the technology fear that it would create even greater staffing instability. The author concludes that with careful legislative drafting, this could be an important elder abuse prevention tool.

10. P5672-18
Lingler, J.
Ethical Issues in Distinguishing Sexual Activity from Sexual Maltreatment among Women with Dementia
Journal of Elder Abuse and Neglect; Vol. 15 (2), 85-102; 2003.
Journal article (scholarship)
This article considers the ethical complexities of distinguishing between sexual activity and sexual abuse of women with dementia. In particular, the author challenges the National Center on Elder Abuse (NCEA) definition of sexual abuse as "nonconsensual sexual contact of any kind with an elderly person." To illustrate the difficulty in assessing sexual abuse, she presents a case study of a loving couple who remains sexually active after the wife becomes moderately cognitively impaired. The husband is viewed as a "model caregiver" by all health and social service professionals involved. At issue is the impaired individual's ability to provide consent. Overly simplified definitions appear limiting and detrimental to the vulnerable spouse. The author presents a paradigm for the contextual ethical analyses of such situations that is based upon feminist bioethical approaches, and contends that "some, if not most, sexual activity between loving spouses may be morally permissible even when one partner has dementia and cannot consent." The approach involves assessment of various forms of oppression, such as ageism plus sexism, and hypercognitivism, which places a higher value on rationality and productivity as opposed to other elements of an individual's humanity. The trust level between the partners before the onset of dementia is an important consideration.

11. P5422-28
Roy, K.
Sleeping Watchdogs of Personal Liberty: State Laws Disenfranchising the Elderly
Elder Law Journal; Vol. 11; 2003.
Journal article (legal scholarship)
Generally, voting rates among the elderly are higher than those of other age groups, yet elders under guardianship are at risk for disenfranchisement. This note presents a detailed legal discussion of voting legislation throughout the U.S. that serves to disenfranchise the elderly. Eleven states specifically prohibit anyone under guardianship from voting due to presumed incompetence, and 44 states have either statutes or constitutional provisions that permit disenfranchisement. The article describes the history of such decisions and its current impact upon elderly voters. A number of guardianship processes are highlighted, such as that of Florida, which specifies that the judge must appoint an examining committee with experts in the disciplines of aging to determine competency. However, inconsistencies in professionals' abilities to assess dementia are a critical concern. Recent trends indicate that greater emphasis is being placed upon functional ability and not merely diagnosis of mental illness and mental disability to determine competency. Carroll v. Cobb (New Jersey, 1976) and Doe v. Roe (Maine, 2001) are among the lawsuits presented.

12. P5681-42
Sandusky, S.
The Lawyer's Role in Combating the Hidden Crime of Elder Abuse
The Elder Law Journal; Vol. 11; 2003.
Journal article (legal scholarship)
In this legal note, the author attempts to describe how lawyers can ethically assist their elderly clients who appear to be abused. After presenting discussion regarding the scope of the problem in the U.S., she presents hypothetical case scenarios to illustrate the complexities of dealing with abused clients who refuse to allow the attorney to report the mistreatment to protective services. The duty of confidentiality, as described in the American Bar Association's Model Code of Responsibility, is examined in as it applies to a competent client. The limited exceptions to the duty of confidentiality are considered, along with The Revised Model Rule 1.6 (not yet adopted by any states) that considers the threat of substantial harm as a proposed exception. The options of withdrawal and/or breaching confidentiality are discussed and considered ineffective in either protecting the client or fulfilling her legal needs. In the second scenario, the vagueness and therefore limited guidance from the Model Code when addressing a questionably competent client is explored, along with the pros and cons of the role of attorney as de facto guardian. The author recommends that the attorney persist in attempting to gain consent from the competent client in order to report the mistreatment or to take other protective action. In addition, the process of "gradual counseling" is presented as a means to understand the client's resistance to such interventions and to address the underlying causes (such as fear of institutionalization, or fear of harming the family unit), and to present the client with additional resources, such as hotline information, alternative housing options, elder abuse programs in the area, and family counseling. In dealing with the questionably competent or incompetent client, the attorney needs to recognize that despite the cognitive limitations, he or she may have valid reasons for not wanting to report the abuse. Therefore, a contextual approach to determining capacity to make this decision should be combined with the gradual counseling process.

13. P5216-6
Sutton, L., Erlen, J., Glad, J. & Siminoff, L.
Recruiting Vulnerable Populations for Research: Revisiting the Ethical Issues
Journal of Professional Nursing; Vol. 19 (2), 106-112; March-April 2003.
Journal article (scholarship)
This article provides a general discussion of the ethical and practical considerations of recruiting vulnerable populations for medical research. The need to balance freedom of choice with protection from harm is considered, as health care personnel may unintentionally limit the participation of vulnerable patients. Collaboration between the researchers, ethicists and health care providers is essential.

14. P5367-4
Turkoski, B.
Is This Elder Abuse?
Home Healthcare Nurse; Vol. 21 (8), 518-521; August 2003.
Journal article (scholarship)
In this article, an ethical dilemma involving a home health care nurse is explored. In the case scenario, an older, somewhat physically incapacitated man is being cared for by his grandson's family. Concerns over neglect arise as the primary caretaker is not changing his dressing daily and he is left alone with a ten year old great-grandchild on occasion. The patient reports that he is happy and wants to continue in his family's care. The home health care nurse brings the case to the attention of her agency's ethics committee, where the concepts of beneficence, nonmaleficence, justice and autonomy are considered. Rather than report the family to adult protective services, a meeting is arranged for the nurse, social worker, grandson and his wife. The clinical and social needs of the client are emphasized and a viable care plan is devised, including a more detailed training in the procedure of dressing changes and in developing respite care alternatives.

15. P5508-4
Welsh, S., Hassiotis, A., O'Mahoney, G. & Deahl, M.
Big Brother is Watching You - The Ethical Implications of Electronic Surveillance Measures in the Elderly with Dementia and In Adults with Learning Difficulties
Aging & Mental Health; Vol. 7 (5), 372-375; September 2003.
Journal article (scholarship)
In this article, the authors discuss the ethical considerations of using surveillance technologies, particularly electronic tracking and tagging, in order to monitor the behavior of incapacitated adults. Observing that wandering is often a behavior among community dwelling residents with dementia that precipitates institutionalization, the authors suggest that these technologies could afford such individuals greater freedom. Additionally, the use of these devices among nursing home residents may provide them with a more varied lifestyle and may lead to less agitation and behavioral disturbances. The effect of these technologies upon human rights and civil liberties is considered. (England/U.K.)

2002

16. A31-2
Brisk, W. & Flynn, J.
Combatting Attorneys Who Abet Financial Abuse of the Elderly (Advocacy and Litigation SIG Column)
NAELA News (National Association of Elder Law Attorneys);
p5-p6; November/December 2002.
Journal article (legal scholarship)
This article describes the necessity of scrupulous and ethical adherence to the Code of Professional Responsibility when lawyers (particularly elder law attorneys) are transferring property. In particular, the lawyer must communicate directly with the client and determine that he or she is not acting under undue influence. Failure to do this would result in financial abuse or exploitation.

17. P5743-36
Dresser, R.
Ethical and Policy Issues in Research on Elder Abuse and Neglect (from Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America; Bonnie, R. & Wallace, R., eds.; National Academy Press, Washington, D.C.; 2002.)
Chapter (scholarship)
In this chapter, from Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, the author examines the complex ethical and policy issues surrounding elder abuse research by using the Belmont Report as an ethical framework for the analysis, and the Federal Policy for the Protection of Human Subjects as the framework for policy analysis. The Belmont Report describes three ethical principles for research: respect for person, beneficence, and justice. The chapter explores which projects are considered research versus other information gathering activities, and which projects are subject to federal oversight. Standards for evaluating decisional capacity are considered as they impact upon the participant's ability to make informed choices and to provide consent for participation. If participants are incapable of providing informed and voluntary consent, researchers should obtain informed and voluntary consent from a research representative deemed concerned with safeguarding the participant's well-being. Beneficence is applied when researchers and the institutional review board (IRB) evaluate the risk for harm with the potential benefit of the study. Discussion includes recommendations on minimizing risks to participants of elder abuse research that could lead to harmful consequences, such as violations of confidentiality and the potential for physical and psychological harm. Ethical conflicts arising from elder abuse research center on two areas: the researcher's response to suspected elder abuse; and the need for information disclosure. (This publication is currently accessible online at the National Academy Press web site at http://books.nap.edu/books/0309084342/html/index.html and may also be ordered in hardback by contacting 1 800-624-6242. Price: $52.15.)

18. N4990-4
Hughes, J. & Louw, S.
Confidentiality and Cognitive Impairment: Professional and Philosophical Ethics
Age and Ageing; Vol. 31 (2), 147-150; 2002.
Journal article (scholarship)
This commentary addresses some of the ethical and legal difficulties in adhering to the General Medical Council's guidelines on confidentiality in treating and managing the care of patients with dementia. Issues concerning physicians, social workers and other health care professionals are discussed. (U.K.)

19. P5065-8
Kingsley, B.
Patterns of Knowing in Professional Practice in Dealing with the Abuse of Older People
Contemporary Nurse: A Journal for the Australian Nursing Profession; Vol. 12 (2), 136-143; April 2002.
Journal article (scholarship)
In 1978, Barbara Carper presented a conceptual framework of "professional knowing" for nurses. In this article, the author applies the four patterns of knowing (empirical, or scientific, aesthetic, personal and ethical) to the practice of addressing suspected elder abuse and neglect. Nurses are encouraged to engage in all patterns of knowing, including self-awareness, in order to better detect and assist patients experiencing this mistreatment.

20. P5056-21
Lewis, T.
Perspectives on Elder Law: Pain Management for the Elderly
William Mitchell Law Review; Vol. 29 (1); 2002.
Journal article (legal scholarship)
This essay describes the ethical, legal and physical complexities of pain management when treating the elderly. Two illustrative cases are presented. In State of Kansas v. Naramore, Dr. Naramore was initially convicted of attempted murder of a terminally ill patient, following the increase of her pain medication after discussing the potential consequences with her family. In the second case, Bergman v. Chin, the family was initially awarded $1.5 million as Dr. Chin was held liable for failing to adequately treat the patient's pain. Reasons for the difficulties in accurate pain assessment of the elderly and recommendations to ameliorate some of these problems are also discussed.

21. P5049-7
Linzer, N.
An Ethical Dilemma in Home Care
Journal of Gerontological Social Work; Vol. 37 (2), 23-34; 2002.
Journal article (scholarship)
In this discussion, the author uses a case scenario to explore the intricacies of ethical dilemmas in home care. The principles of autonomy, beneficence, dignity and paternalism are considered as they impact upon the social worker's decision to intervene when clients, who appear self-neglecting due to dementia or physical incapacity, refuse services. The decision-making capacity is at the heart of this dilemma.

22. P5542-16
Wilson, G.
Dilemmas and Ethics: Social Work Practice in the Detection and Management of Abused Older Women and Men
Journal of Elder Abuse and Neglect; Vol. 14 (1), 79-94; 2002.
Journal article (research)
This article presents the themes identified throughout the interviews with social workers serving older clients of the assessment and care management department of a social service area. Twenty-four open-ended interviews were conducted with front line social workers and first line managers (approximately half of the staff) regarding their observations, understanding of, and attitudes towards elder abuse. Dominant themes identified include shortage of resources and mistrust of residential care. All participants expressed an "oversimplified" awareness of elder mistreatment. "Silences" included a lack of awareness of differences and diversity, and the complexity of the cases seemed to be unappreciated. (U.K.)


2001

23. N4855-20
Beaulieu, M. & Spencer, C.
The Emergence of Older Adults' Personal Relationships in Canadian Law
International Journal of Law and Psychiatry; Vol. 24 (2-3), 213-232; 2001.
Journal article (legal scholarship)
This article examines the intricacies of the legal interpretations, and interventions, regarding older adults' personal relationships. In part one, the authors present socio-cultural influences that impact the process of aging in Canada. In part two, the authors present a summary and analysis of Kim v. DeCamillis, a case involving a relationship between a septuagenarian and his late-life partner, a Korean born woman thirty-five years his junior. During their four and a half year live-in relationship, Mr. DeCamillis' family made legal arrangements to safeguard the father from exploitation, despite his apparent competence to make such decisions for himself. In part three, the authors consider how ageist and paternalistic attitudes of practitioners can negatively impact upon the older individual's right to self-determination regarding personal relationships.

24. N4655-16
Georgia Law Review Association
Symposium: Joint Conference on Legal/Ethical Issues in the Progression of Dementia: Foreword
Georgia Law Review; Vol. 35; Winter 2001.
Journal article (legal scholarship)
This foreword outlines the papers included in this edition of law review that were originally presented at the symposium of the Joint Conference on Legal/Ethical Issues in the Progression of Dementia, held at the Center for Continuing Education at the University of Georgia (11/29-12/2/2000). Seventy-five multidisciplinary experts participated in working groups that addressed the following issues encountered in addressing the needs of a dementia client: legal planning, autonomy versus public safety, research consent, treatment choices, end-of-life issues, genetic discrimination by long-term care insurers, legal representation (including ethical consideration when assisting families) and dispute resolution. The conference structure was organized around the case study of an Alzheimer's patient and her family's involvement. The symposium was sponsored by the Borchard Foundation Center on Law and Aging, the Alzheimer's Association, the American Bar Association's Commission on Legal Problems of the Elderly, the National Academy of Elder Law Attorneys and the University of Georgia School of Law.

25. N4656-25
Georgia Law Review Association
Symposium: Joint Conference on Legal/Ethical Issues in the Progression of Dementia: Recommendations of the Joint Conference
Georgia Law Review; Vol. 35; Winter 2001.
Journal article (legal scholarship)
This paper reports the recommendations developed during the symposium of the Joint Conference on Legal/Ethical Issues in the Progression of Dementia, held at the Center for Continuing Education at the University of Georgia (11/29-12/2/2000). This article reports upon the recommendations that were generated by multidisciplinary working groups at the conference regarding the needs of dementia clients including topics such as legal planning and representation, medical and treatment choices, research consent, discrimination, and other ethical considerations. (For an overview of the symposium, see the above listed entry for CANE file # N4655-16.)

26. N4760-13
Kadushin,G. & Egan, M.
Ethical Dilemmas in Home Health Care: A Social Work Perspective
Health and Social Work; Vol. 26 (3), 136-149; August 2001.
Journal article (research)
The expansion of home health care offers not only new opportunities for social workers, but accompanying ethical dilemmas. This article discusses the survey results of 364 home health care social workers regarding the frequency of (and degree of difficulty in resolving) four ethical considerations. Areas assessed were access to services, advance directives, mental competence and self-determination. There was consensus that all areas except ethical conflicts over advanced directives were encountered frequently. The survey also explored the social worker's awareness of the stakeholders involved in the conflicts (such as the client, the agency administrator, the staff in the agency, etc.) as well as the resources available to assist in resolving the dilemma (colleagues, supervisor, code of ethics, etc.).

27. A451-9
Longan, P.E.
Middle-class Lawyering in the Age of Alzheimer's: the Lawyer's Duties in Representing a Fiduciary
Fordham Law Review; Vol. 70; December 2001.
Journal article
This article explores the legal intricacies of addressing potential financial abuse by guardians of elderly, incapacitated wards. The Model Rules of Professional Conduct and the Restatement of the law Governing Lawyers are considered as they relate to the ethical conflicts of maintaining client confidentiality while preventing irresponsible, fraudulent or criminal actions. Both the vulnerability of the ward and the susceptibility of the guardian to commit such acts are discussed. A spectrum of professional options are outlined and include counseling without the right to disclose as the least intrusive, and a duty to discover as the most extreme. Also presented are the more moderate, but perhaps more effective interventions of optional and mandatory disclosure.

28. N4645-51
Loue, S.
Elder Abuse and Neglect in Medicine and Law
The Journal of Legal Medicine; Vol. 22, 159-209; June 2001.
Journal (scholarship)
This is a comprehensive overview of the medical and legal aspects of elder mistreatment. Discussion includes comparisons (and highlights discrepancies) of definitions, theories and state legislation addressing physical, psychological, sexual and financial abuse, neglect, and self-neglect. Ethical dilemmas surrounding mandatory reporting and defining self-neglect versus right to self-determination (Patient Self-Determination Act or PSDA) are examined, among many other salient concerns. Also noted is the scant presence of elder abuse as a training area in health care educational curricula.

29. N4722-6
Lowenkopf, E.
Legal Issues of Geriatric Patients: Competency and Decision-Making
Geriatric Times; Vol. II (6); November/December 2001.
Online article
This is a comprehensive overview of competency and decision-making, particularly as it relates to older patients dealing with medical and end-of-life issues. The author describes the development of legal codes and ethical standards that protect the rights of self-determination. Acknowledging that there are varying definitions of competency, the four generally recognized standards of competency are discussed: (1) the ability to appreciate the situation and its consequence; (2) the capacity to understand relevant information; (3) the ability to manipulate information rationally; (4) the ability to communicate choices clearly. A number of key concepts are emphasized, including the need for accurate diagnosis, the recognition that there are many degrees of competency, and that the determination of competency is a legal determination. Discussion also includes the use of health care proxies and advance directives and consultation with hospital ethicists when necessary to ensure that patients' wishes are honored if at all possible. (Note: This article is available online only at http://www.geriatrictimes.com/g011133.html)

30. N4650-34
Moskowitz, S.
Upper-level Courses: On Golden Pond - Integrating Legal Issues of the Elderly into Family Law
Stetson Law Review; Vol. 30; Spring 2001.
Journal article (legal scholarship)
Noting that law school curricula are not reflective of the needs of the aging American population, this attorney explores areas of family law that could be enhanced to better serve elders. Issues surrounding marriage, multi-generational families, intra-family support obligations, elder abuse and ethics are addressed. Among other points, the author emphasizes the need to properly identify the client when an elder is brought to an attorney for assistance with financial planning by a friend or family member.

31. N4673-11
Nagpaul, K.
Application of Elder Abuse Screening Tools and Referral Protocol: Techniques and Clinical Considerations
Journal of Elder Abuse & Neglect; Vol. 13 (2), 59-78; 2001.
Journal article (scholarship)
This article is included in an issue of JEAN that focuses on the development, implementation and evaluation of the Ohio Elder Abuse Screening Tools and Referral Protocol (STRP), which was developed by the Benjamin Rose Institute and designed to assist service providers in the detection of elder mistreatment and domestic violence in later life, and to offer guidance for appropriate referral. The article explores the clinical implications of using this assessment. Through case study illustration, practical aspects of the interview, evaluation and referral processes are discussed. Interviewing techniques, ethical dilemmas regarding self-determination and confidentiality, considering how to best intervene within complex family systems, and distinguishing elder abuse from domestic violence (or intimate partner violence) are among clinical issues presented.

32. P5741-10
Wendler, D. & Prasad, K.
Core Safeguards for Clinical Research with Adults Who Are Unable to Consent
Annals of Internal Medicine; Vol. 135 (7), 514-p523; October 2001.
Journal article (scholarship)
Specific protections for persons unable to consent to clinical research are not specifically included in the U.S. Code of Federal Regulations. In this article, the authors present a side-by-side comparison of core ethical safeguards proposed by four U.S. and two international advisory groups. Recommendations from the National Bioethics Advisory Commission (NBAC), the National Institutes of Health, the Maryland Attorney General's office, the New York Department of Health advisory group, the Canadian Tri-Council, and the Council of Europe are outlined, and the recommendations are synthesized into current proposals. The variables considered are the population to be covered, the institutional review board (IRB) risk-benefit assessment, the consent assessment, the necessity requirement, the proxy decision maker and evidence of participant's preferences, respect for patient assent and dissent, and consent and participation monitors. The core safeguards proposed are designed to minimize risk of subject abuse while ensuring that this population is represented in medical research. A table is provided that illustrates the application of these safeguards to specific types of research ranging from minimal to greater than minimal risk-benefit levels.

33. N4729-35
Wood, E.
Symposium Article: Dispute Resolution and Dementia: Seeking Solutions
Georgia Law Review; Vol. 35; Winter 2001.
Journal article (legal scholarship)
This symposium article explores the use of "alternative dispute resolution" (ADR) with dementia patients while providing an overview of various perspectives in conflict resolution. Examples of common disputes in a variety of settings (from private residence to nursing homes) are used to demonstrate different stages where ADR may be appropriate. The examples present a wide range of issues, from everyday conflicts involving habits and preferences, to key life decisions, such as whether or not to insert a feeding tube. Among the points of discussion are the ways that the mediation process may be enhanced to assist cognitively impaired participants, such as utilizing support persons and surrogates, accommodations, and alternative communication techniques. Ethical considerations, including the inherent "fairness" of the process, confidentiality, and neutrality are also considered.


2000

34. N4869-4
Bradshaw, R.
Preventing Abuse of Vulnerable Adults
Journal of Adult Protection; Vol. 2 (1), 35-38; February 2000.
Journal article (scholarship)
This is a policy paper of United Kingdom Central Council (UKCC) regarding professional ethics and elder mistreatment. The UKCC, the regulatory body for nursing, midwifery and health visiting, garnered input from practitioners, care users and care providers in developing expanded definitions of mistreatment and practical guidelines to assist in prevention, detection and management of abuse. The expanded definitions and principles are outlined.

35. L4545-5
Johnson, T.F.
Ethics in Addressing Mistreatment of Elders: Can We Have Ethics for All?
Generations; p81-p85; Summer 2000.
Journal article (scholarship)
In this article, the author discusses three ethical approaches in dealing with elder mistreatment. Using a case study, both the "stakeholder" (individualistic) and the "social compact" (reciprocity) perspectives appear problematic. A "communicative ethics" approach is proposed as a resolution model that promotes relative, not absolute, decision-making through advocacy, deliberation, negotiation and consensus. (This article is part of a special edition of Generations dedicated to the recognition of the problem of elder abuse.)

36. P5742-11
Sasson, S.
Beneficence versus Respect for Autonomy: An Ethical Dilemma in Social Work Practice
Journal of Gerontological Social Work; Vol. 33 (1), 5-16; 2000.
Journal article (case study)
This article presents a recent case conflict at a nursing home that demonstrates ethical complexities surrounding a physically disabled resident's desire to be discharged. Ethical dilemmas between self-determination and beneficence are evident as the physician refused to authorize discharge due to his belief that the patient would be unable to function without 24 hour nursing care and supervision. Furthermore, the social worker was unable to obtain a commitment from a future caretaker for discharge planning. Both the utilitarian theory (which maintains that the outcome of actions determine whether the decision is right or wrong) and the deontological theory (which maintains that actions are considered right or wrong based upon guiding principles such as truthfulness and justice) are applied to the case scenario.

37. N4728-9
Welfel, E.R., Danzinger, P. & Santoro, S.
Mandated Reporting of Abuse/Maltreatment of Older Adults: A Primer for Counselors
Journal of Counseling and Development; Volume 78, p284-p292; Summer 2000.
Journal article (scholarship)
This aptly titled article provides an overview of the topic of elder mistreatment in terms of the counselor-client relationship. The first section defines the five major categories of abuse and neglect, providing case examples. The second section focuses on the legal reporting requirements regarding suspected abuse, and includes a concise chart on mandatory reporting requirements for the fifty states and the District of Columbia. The chart illustrates such variations in the reporting laws as victim's age, subtype of abuse, whether there is a time frame for reporting, and whether there is a penalty for failing to report. The following section addresses the difficulties of assessment, while the final section explores ethical guidelines in determining the need to report. Practical clinical recommendations are provided to assist the counselor in meeting the legal and ethical standards of mandatory reporting while maintaining a therapeutic alliance with the client.


1999

38. K4232-12
Simmons, P. & O'Brien, J.
Ethics and Aging: Confronting Abuse and Self-Neglect
Journal of Elder Abuse & Neglect; Vol. 11 (2), 33-54; 1999.
Journal article (scholarship)
A specific case involving a 77-year-old male is presented to exemplify the dilemmas facing health care providers treating older patients. Self-neglect is explored in detail and the issues of reporting and intervention are discussed using real cases as examples to illustrate the often conflicting and difficult choices providers must face when autonomy may not be in the best interest of the patient. The issues of refusal of treatment and determination of decisional capacity are also discussed and recommendations are made to minimize the intrusion of treatment into the patient's life.

39. K4231-10
O'Brien, J., Thibault, J., Turner, L. & Laird-Fick, H.
Self-Neglect: An Overview
Journal of Elder Abuse & Neglect; Vol. 11(2), 1-19, 1999.
Journal article (scholarship)
This article explores the complexity and definitional problems of self-neglect caused by its subjectivity to changes in context. Some of the issues discussed are: epidemiology, etiology, detection, ethical/legal issues, management/intervention, and outcomes. The main challenges to detection and prevention are discussed with regard to autonomy and personal rights. Previous studies on this subject are compared and general conclusions are reported.


1996

40. K4325-4
Mixson, P.
How Adult Protective Services Evolved, and Obstacles to Ethical Casework
Aging Magazine; p14-p17; Spring 1996.
Journal article (scholarship)
This article provides a brief definition of Adult Protective Services (APS), as well as a history of its origin. The federal involvement of APS is discussed, with particular emphasis placed on Title XX of the Social Security Act. It also includes an outline of typical APS guidelines and a discussion of various conflicts of interest that can lead to problems within the program.