Ethical Issues in Gerontological Practice

Even as a lay person, not in the field of aging, other than being an older adult and in the process of aging, I found a recent Maryland Gerontological Association forum on "Ethical Issues in Practice with Older Adults" at Vantage House, in Columbia, both educational and enlightening. After a welcome by MGA president Virginia Thomas, of Columbia, Reba Cornman, MSW, Geriatrics and Gerontology Education and Research Program, University of Maryland Baltimore, introduced the speaker, saying that the presentation would provide a framework for approaching the special issues gerontologists face in working with older adults in a variety of settings.

The speaker was Barbara Soniat, MSW, PhD, who is an associate professor and director of the Center on Global Aging at the National Catholic School of Social Service at Catholic University in Washington, D.C. She has worked in the field of gerontology for over 30 years.

The audience was made up primarily of social workers, a few nurses, an occupational therapist and others, who are working in the areas of assisted living, hospice, medical day care, affordable housing/independent living for seniors, managed care and adult protective services. Continuing Education Units were given for those professionals who needed them.

Barbara provided some definitions in her handout that might be useful here. Ethics is a branch of philosophy that studies human conduct, with emphasis on the determination of right and wrong; just or unjust. Ethical dilemma is a situation in which one is unsure about what is right or what is good; or when there is a conflict between opposing moral systems or obligations (Abramson, M. 1985). Paternalism is overriding a person's wishes or actions for beneficent reasons, based on concern for the person's "own good." Justifiable Paternalism suggests that the overriding of a person's wishes or actions is justified if certain conditions exist. Abramson proposes the following conditions: The individual does not have the capacity to make and informed choice. A mentally incompetent person is unable to comprehend the possible consequences of an action. The consequences of not intervening may be far reaching and irreversible. And, Temporary interference with a person's liberty ensures future freedom.

There are different levels of ethical decision making and many variables to be considered in the process. Client cases aren't black and white but are often convoluted and extremely difficult, causing ethical dilemmas for the practitioner. There are so many different practice settings the older adult client may be in, such as living in their own home, with family, independent older adult communities or assisted living facilities; outpatient medical practices; inpatient-hospital settings; and nursing home settings. The aging population is very diverse and is continually changing, so decisions for clients may vary based on age (decision would be different for someone age 60 versus someone age 100); culture; socio-economic factors; and functional and mental health. All of these elements influence ethical decision making.

Barbara Soniat, who lives in Columbia, gave a personal example. She is originally from Louisiana, and her mother who still lives there has Alzheimer's. She is the only child in the family who went to college. When she goes home to take care of her mother, she looks for assisted living facilities for her. She found one but her siblings won't hear of their mother going into a facility. They will take care of her at home. Barbara said that she cannot be authoritative in this situation, lording it over her siblings with an "I know better" attitude based on her years in the field of aging. Barbara's daughter took a leave of absence from her job and she and her 8-year-old daughter moved to Louisiana to take care of her grandmother/great-grandmother. Barbara takes her turn in caring for her mother but this is not the care plan she would have ever chosen for her mother.

Barbara also discussed one of her early cases, when she was working in New Orleans. It was about a Ms. Bell, who had worked hard and purchased a home in the Garden District of New Orleans. I have been there and it is a lovely area. She swept her sidewalk every day and took pride in her lawn. One day a neighbor allowed his dog to do his business on her lawn and Ms. Bell hit him with her broom. That neighbor went to the emergency room for his "injury" and later filed a suit against her. Ms. Bell stood on her principles that he was the one that did something wrong, not her. So, she never responded to any correspondence on the matter and eventually a lien was placed on her home. She was bodily removed from her home and placed in a nursing home. Her home was sold at public auction to retrieve the $750 the neighbor had been awarded for damages. This case raised the ethical questions: Was she capable of making decisions for herself? Why wasn't she referred to some agency that could have helped her? Was there some type of intervention that would have preserved her home? Barbara said that this case made its impact on how she viewed justifiable paternalism and how she used it in her career.

The patient populations that are most challenging in terms of ethical issues are persons with impaired capacity for decision making; those who lack adequate family and an informal support system to assist them in decision making; those with disagreements and conflicts within families; and patients with preferences, which conflict with professional recommendations. One of the variables the practitioner faces is ageism or age discrimination, especially against older adults, making sure that ageism isn't a factor in their concern for or view of the client.

Older adults frequently resist accepting help. They often don't want to share the information necessary for an evaluation of their situation. They are also often fearful of what will happen if they expect or accept help. There are a number of tools that we as older adults can use to maintain our independence. We need to continue to become aware of and educated about aging and decision making. We need to be aware of the benefits of advanced directives and durable powers of attorney for healthcare. We also need to communicate in writing and articulate our values and preferences to family members, healthcare providers and clergy and spiritual guides before we lose our capacity for decision making, so that these members of "our team" will be totally aware of what we would want in a given situation. By "taking charge of our future," and utilizing these tools, we can stay in control throughout our life. According to Barbara, less than 10 percent of the general population has advance directives.

In closing, I thought I would share with you a quotation that Reba Cornman decided not use in her introduction of Barbara Soniat because of its length, but shared with me. It is from the Caring Matters website, in the section "Defining Relationship-Centered Care." Under the heading "Relationships Among Healthcare Practitioners," it states, "Effective, empathic care requires a community of practitioners who commit themselves to working together to serve the complex matrix of individuals' needs in health and illness. Relationships among practitioners include those within or across disciplines, and those between practitioners and practitioners-in-training. These relationships require teamwork, shared values, learning from and making use of the expertise of others, helping others learn and develop, integrating services at individual and systems levels, and setting aside issues of specialization, hierarchy, and privilege. Such relationships serve the needs of healthcare providers to care for one another and give and receive the support and encouragement that produces personal and professional maturation and more effective patient care."

I have really just scratched the surface here. There was so much more material presented at the forum. Through my attendance at this forum, I gained a much better understanding of the complexity of healthcare practitioners' relationships and interactions with their clients and have a newfound empathy for the ethical dilemmas they face every day and the hard decisions they have to make.

I can't close without telling you about an educational opportunity you should consider. It is the Maryland Gerontological Association's 29th Annual Conference Wednesday, June 22 from 8 a.m. to 4 p.m. at Charlestown Retirement Community in Catonsville. The theme is "Staying Healthy, Active and Involved in the Community, Optimizing Your Resources." For more information, call 410-550-0926 or go to I hope to see you there.

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