11 - Ethical & Legal Issues in Aging Flashcards
Consent
- Informed and voluntary, can be withdrawn at any time
Accurate, complete, relevant information
Simple, clear, non-technical language
How can consent be provided
1) written consent
2) implied consent
○ Ex. When you walk into clients room and ask if you can take their bp (nothing is written down - there is NO minimum age, we must assess clients overall ability to understand and comprehend
What is the Healthcare Consent Act (HCCA)
- Governs who can make a treatment decision for someone who is incapable of making their own decision (substitute decision makers)
- is concerned with the ability to make decisions in relation to specific treatment, admission to care facilities or personal assistance services
What is the Substitute Decisions Act (SDA)
- concerned with persons who need decisions made on their behalf on a continuing basis
- involves the formal appointment of a decision-maker through a power of attorney document, through the Office of the Public Guardian and Trustee (PGT) or through a court appointment
- only applies when client is unable to make decisions
What is the Hierarchy of Substitute Decision-Makers?
- Guardian appointed by the court (manage health care and personal care decisions)
- Power of attorney (for person care)
○ Designed by the client to anyone
○ Does not need to be a family member - Appointed by consent and capacity board
○ If capacity is questioned, but client disagrees with that, they can make an appeal - Spouse or partner
- Child or parent (>16)
○ Technically only need consent from 1 parent - Parent whop has a right of access
- Brother and sister
- Any other relative
- Public guardian and trustee (last resort)
When does an SDA make decisions?
- An SDA Will only make your healthcare decisions when you are NOT mentally capable of making a decision
Ex.
1. A time when you are unconsciouse.g.
2. In advanced dementia
3. During a temporary time of incapacity
- Alcohol or drug intoxication
- Medication side effects
- Infection causing confusion
Power of Attorney
- Written document in which you name someone to be your attorney
- an attorney is a type of SDM
To sign a POAPC you must be:
- over the age of 16
- mentally capable of understanding the document and any instructions you may include.
- You do not need to go to a lawyer to complete this, however legal advice may be helpful
- Inform the person(s) you appoint. Your family members and healthcare providers also need to know who this is.
- Healthcare providers may ask for a copy of the Power of Attorney document.
What is Advanced Care Planning
What: Sharing your wishes for future healthcare or personal care with those close to you, SDM, and POA
Who should engage: Any adult
Who can be an SDM?
When are moments of ACP review?
5 Components of Advances Care Planning
- Think: about who you want as SDM, resuscitation status etc,.
- Learn: about your health and current conditions
- Decide: on your SDM’s
- Talk: about it with family and ppl close to you
- Record: values, wishes, beliefs
Questions to guide ACP?
- What gives your life meaning?
- What brings quality to your life?
- What worries or fears do you have about your future health?
- Think about past medical care a family member or friend received during an illness or at the end of life. Were there things that could have been done better?
Wishes and Values for End of Life
What do I value most? What brings quality or meaning to my life?
What have I been told about my illnesses?
What information would I like to find out?
What concerns or worries do I have about how my health may change in the future?
What might I trade for the chance of gaining more of what I value or what’s important to me (e.g. more time with family)?
If you were near the end of your life, what would make this time meaningful?
What is the importance of communicating ACP?
- Palliative care client is seen in ER
- Can be assumed that client wants interventions/procedures… IV fluids, intubation etc.
- People in palliative care would only go to the ER in an extreme emergency situation
○ Ex. treatable pneumonia
How death has changed?
In 1900’s
- death occurred mainly in the home
- Family; eldest daughter provided care
- causes of death were Infections (pneumonia, TB), Diarrhea
Now
- main causes of death are heart attack, stroke, cancer
- We can delay death now/extend life: antibiotics, new tech
Why is EOL Decision-Making Difficult?
- People don’t like to talk about death
- Fear of giving up
- Don’t know options available to them
- Uncertainty about client wishes
- Cultural, spiritual, and religious traditions
- Previous experiences with death
- Emotional component
What is Palliative Care?
- A philosophy and approach to care
- Relief of suffering and symptom management
- Can be used in junction with curative treatments (is not curative itself)
- Hospice - refers to last months of life, place of care as a specialized facility
Issues with palliative care
- few people (< 8%) in need have access to hospice/palliative care
What is the importance of palliative care?
When people receive palliative care services they report:
- fewer symptoms of their illness
- a better quality of life
- a greater level of satisfaction with their care
Ways of Dying
1) “Allow Natural Death”
- Withhold life saving technology
2) Assisted
- Giving people the tools they need to die, patient initiates
3) Active
- Someone else does e.g. Medical Assistance
Are these Ethical?
What is MAID?
2015
- the Supreme Court of Canada decided to allow physician-assisted suicide
June 2016
- federal government passed the MAID Act, which established the eligibility criteria and procedural safeguards for medically assisted suicide
How has the “term” euthanasia changed?
- Active Euthanasia
- Physician Assisted Suicide
- Physician Assisted Dying
- Medical Assistance in Dying
2 Methods of MAID
Method 1:
- a physician or nurse practitioner directly administers a substance that causes death
ex. an injection of a drug.
Method 2:
- a physician or nurse practitioner provides or prescribes a drug that the eligible person takes themselves, in order to bring about their own death
- sometimes called self-administered medical assistance in dying
Ethical Considerations of MAID
What about mature minors? Children?
-Conscientious objection
- Some practitioners may refuse MAID due to religious beliefs and values
Mental illness
- Originally, people with mental illness could not access MAID
Advanced directives
- Should you be able to seek advanced directives
What about Medical Tourism?
What if the patient and family wishes are in disagreement?
Eligibility Criteria of MAID
You must:
1) be eligible for health services funded by a province or territory, or the federal government
- You may also be eligible if you meet your province or territory’s minimum period of residence or waiting period.
2) be at least 18 years old and mentally competent
- This means being capable of making health care decisions for yourself.
3) have agrievous and irremediable medical condition
4) make a voluntary request for medical assistance in dying
- The request cannot be the result of outside pressure or influence.
5) giveinformed consentto receive medical assistance in dying
What defines a grievious and irremediable condition?
You must:
- have a serious illness, disease or disability
- be in an advanced state of decline thatcannotbe reversed
- experience unbearable physical or mental suffering from your illness, disease, disability or state of decline thatcannotbe relieved under conditions that you consider acceptable
- You donotneed to have a fatal or terminal condition to be eligible for medical assistance in dying
- If your only medical condition is a mental illness, you are not eligible for medical assistance in dying until March 17, 2027
- If you have a mental illness along with other medical conditions, you may be eligible for medical assistance in dying
- Eligibility is always assessed on an individual basis and takes all relevant circumstances into account. However, you must meet all the criteria to be eligible.
What are the procedural safeguards of MAID?
- Have 2 independent medical assessments
- Make a written request signed by an independent witness
- Know that you can withdraw your request at any time
- Provide final consent before receiving MAID
- Give advanced consent, if applicable
Elder Abuse
- prevalence of abuse and neglect is at least 4% in Canada
-T he abuse of older people is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.
- This type of violence violates human rights and includes physical, sexual, psychological and emotional abuse; financial and material abuse; abandonment; neglect; and serious loss of dignity and respect.
Consequences of Elder Abuse
- major QOL issues
- they could experience physical trauma, reduced self worth and dignity, a lost sense of safety and security
- placement in Nursing Home (WHO)
- increased risk of early death
- increased hospitalization and economic costs from investigation procedures, health-care interventions, law enforcement and lost productivity
Types of Abuse
1) Financial:
- most common;
- gain to the abuser, loss to the older adult
2) Psychological:
- verbal/non-verbal
- lessens identity, dignity or self-worth
3) Physical: violence or rough handling causing physical discomfort or pain
4) Sexual: Sexual abuse is any sexual behaviour directed toward an older adult without that person’s full knowledge and consent
- it includes coercing an older person through force, trickery, threats or other means into unwanted sexual activity.
5) Neglect: failure to meet physical and mental well-being needs, also passive
6) Systemic: rules, regulations, policies, or social practices that harm or discriminate against older adults
The Ecological/Life Course Model
1) Individual
ex. physical/mental health, gender, income, coping skills, history of abuse
2) Relationship
ex. family relationships, support network, caregiving dynamics
3) Community/Institution
- community ex: social inclusion/exclusion, access to transit, community support programs
- institution: culture, policies/practices, working conditions
4) Societal
ex. ageism, healthcare system, law, economic and social policy
Risk factors for Abuse and Neglect
- isolation
- lack of support
- cognitive impairments (e.g. dementia)
- responsive behaviours (e.g. verbal or physical aggression)
- living with a person who has a mental illness
- living with people engaging in excessive consumption of alcohol or illegal drugs
- dependency on others to complete activities of daily living (including banking)
- recent worsening of health
- arguing frequently with relatives
Signs of Abuse
Physical/Sexual
- depression, anxiety
- change of behaviour/mood in presence of person abusing or neglecting
- fractures
- signs of hair being pulled
- evasive or defensie responses
- inadequate explanation or documentation of injury
- unexplained burns/bruises
- evidence of sexual abuse (genital infections, trauma)
Financial
- living conditions that don’t match income
- missing personal belongings
- irregularities in money/bank account
- payments to strangers
- inappropriate use of POA
Signs of Neglect
- dehydration
-malnutrition - pressure ulcers/sores
- depression
- despair
- unclean living conditions
- low blood albumin level
- poor oral hygiene/grooming
5 Priorities of WHO
- Combat ageism (as a major reason why issue receives so little attention)
2) Generate more/ better data to raise awareness of the problem
3) Develop and scale up cost–effective solutions to stop abuse of older people
4) Make an investment case focusing on how addressing the problem is money well spent.
5) Raise funds as more resources are needed to tackle the problem
Why do elder adults not report elder abuse?
- Fear of retaliation e.g. from the abuser
- Dependence on the abuser for food, shelter, clothing, and health care
- Afraid they will be put in an institution e.g. LTC Home
- Pride and embarrassment from telling anyone that a family member is harming them, or stealing their money
- Feelings of hopelessness and powerlessness
- Inability to communicate due to language barrier or health/illness
- Believe the police and/or social agencies cannot help them
- Lack of understanding of theirlegal and human rightsor the justice system
- Unaware that abuse is occurring in their lives or within their environment
- Not familiar with who or where to make a report
Is it mandatory to report elder abuse?
- Reporting is mandatory when an older adult resides in a LTC or a Retirement Home and elder abuse is suspected or has occurred.
- The law requires reporting by anyone who knows or has reasonable grounds to suspect that a resident has been, or might be, harmed.
