Exam Flashcards
Medications for age related changes
-decreased body water
-decreased lean tissue
-increased body fat
-decreased albumin
-decreased liver and renal function
-decreased GFR (decreases renal clearance)
-decreased hepatic blood flow
-receptor sensitivity
risk factors for medications
-pathologic processes
-functional impairments
-polypharmacy
-inadequate monitoring
-financial barriers
-insufficient recognition of adverse effects
-inappropriate prescribing
-communication barriers
-lack of information
Changes That Affect the Action of Medications in the Body
-Age-related changes in body composition (i.e., decreased body water and lean tissue and increased body fat, decreased albumin, decreased liver and renal function).
-Medications that are distributed primarily in body water or lean body mass may reach higher serum concentrations and their effects may be more intense.
-Serum concentration of highly fat-soluble substances can increase, so the immediate therapeutic effects are diminished, but the overall effects are prolonged or erratic
STOPP/START
evidence-based screening tool of older persons’ prescriptions
Communication barriers
Older adults reluctant to challenge or question
Fear of appearing ignorant
Hearing and vision impairments
Attitude of impatience on part of health professionals
Language barriers
prescribing cascade
adverse drug reaction mistaken as new medical condition
Medications and Nutrients
-Changes in the gastrointestinal tract can delay or diminish the absorption of medications.
-Medication interactions are likely to occur if the following medications are taken with food: biphosphonates, carbidopa/levodopa (Sinemet), ciproflocacin (Cipro), digoxin (Lanoxin), furosemide (Lasix), glipizide (Glocotrol), levothyroxixin (Synthroid), metformin (Glucophage), metoprolol (Lopressor) and warfarin
medications and alcohol
-Central nervous system depression
-Health care providers often do not accurately assess an older adult’s alcohol consumption.
-Alcohol can alter the therapeutic action of medications and increase the potential for adverse effect
-Over-the-counter preparations may have alcohol as an ingredient.
More susceptible to interactions between alcohol and medications
medications and nicotine
-Associated with tobacco smoking, smokeless tobacco and other nicotine-based products
-Affects therapeutic action of the medication
-Smokers may require higher doses of a medication
-Dosages of medications may need adjustment.
Functional Consequences Associated with Medications in Older Adults
-Altered Therapeutic Effects
-medications need to be monitored more closely in older adults, especially initially and when there is any change in the person’s medical status or treatment regimen
“start low and go slow.”
-Increased Potential for Adverse Effects
-Decline in function, an increased risk for falls and fractures, an increased number of visits for health care services, admission to a hospital or prolongation of a hospital stay
-Anticholinergic Adverse Effects
-Altered Mental Status
-Delirium
Common types of medications with anticholinergic properties
antidepressants, antihistamines, antiparkinson agents, antipsychotics, cardiovascular agents, gastrointestinal agents and urinary antispasmodics
Antipsychotics in People With Dementia
Extrapyramidal side effects, anticholinergic side effects = risks of orthostatic hypotension and falls
tardive dyskinesia
Rhythmic and involuntary movements of the trunk, extremities, jaw, lips, mouth or tongue.
The earliest signs are usually fine, wormlike movements of the tongue.
Other early signs include chewing, grimacing, lip smacking, jaw clenching, eye blinking and side-to-side jaw movements.
Manifestations can begin as early as 3 to 6 months after initiation of antipsychotic medications, and they usually persist even after the causative agent is discontinued.
It is considered an adverse effect of dopamine receptor-blocking agents and serotonin-norepinephrine reuptake inhibitors (i.e., certain antipsychotics and antidepressants)
Tardive dyskinesia deserves special attention with regard to older adults because advanced age correlates with both an earlier onset and increased severity of tardive dyskinesia.
drug induced Parkinsonism
Parkinson-like manifestations.
Manifestations can be reversed if the offending drug is stopped
The condition is often misdiagnosed as Parkinson disease and treated inappropriately with an antiparkinson medication.
Main causative drugs identified in studies include antipsychotics, calcium-channel antagonists, valproic acid and antiepileptic agents
Factors that Increase the Risk for Adverse Medication Effects
Increased numbers of medications
Frailty
Malnourishment or dehydration
Multiple illnesses
An illness that interferes with cardiac, renal or hepatic function
Cognitive impairment
History of medication allergies or adverse effects
Recent change in health or functional status
Medications in any of the following categories: anticoagulant/antiplatelet, antidiabetics, NSAIDs, central nervous system drugs
Barriers to nursing assessment of medications
time limitations
complex medication regimens
lack of a trusting relationship
Scope of medication assessment
All medications and other bioactive substances used
Individual’s understanding of medications
Allergies and adverse reactions
Perception and preferences
Cultural factors influencing medication use
Sources of health care
Observing patterns of medications used
-Ask to see all medications used or have them bring all medication to appointment (both prescription and over-the-counter medications).
-Direct observation of medication containers
Linking the medication assessment to the overall assessment
-Past and present medications: Help identify health issues.
-Identify clues to problems or complaints.
-Assess for residual adverse effects.
-Expected versus actual outcomes of medication interventions
-Functional ability to take medications
-Assessment of the living environment
-Risks for nonadherence
Nursing Interventions to Promote Safe and Effective Medication Management
Medication reconciliation
Teaching about medications and herbs
Addressing factors that affect adherence
Decreasing the number of medications
nociceptive pain
-Physiologic process leads to perception of noxious stimulus as painful
-Way of signaling that something is wrong.
-Caused by tissue damage
-Often localized to the area where damage or injury has occurred.
-Four processes: transduction, transmission, perception and modulation
neuropathic pain
-Caused from damage or dysfunction of nervous system.
-Unlike nociceptive pain, which is typically caused by tissue damage , neuropathic pain is often due to abnormalities in the nerves themselves.
-Abnormal processing of sensory stimuli by central or peripheral nervous system
-Can occur in the absence of immediate tissue damage or inflammation
acute pain
-Sharp, immediate pain from injury to tissue
-Time limited and responsive to analgesic
persistent pain
-lasts longer than 3 to 6 months or beyond the expected time of healing
-Continues for prolonged period; may or may not be associated with a recognizable disease process
cancer pain
-Complex phenomenon caused by cancer itself
-Can be acute, persistent, nociceptive, neuropathic or a combination of these types
-Caused directly by cancer and indirectly by the effect of cancer
Functional Consequences of Pain
Diminished physical function
Psychosocial effects
Sleep disturbances
Weight loss
Increased dependency
Decreased quality of life
Social isolation
causes of pain in older adults
Widespread problem for older adults
Chronic conditions and diseases of older adults
Arthritis pain
Postherpetic neuralgia
Back problems
Fibromyalgia
Diabetic peripheral neuropathy
cultural aspects of pain
-Cultural factors: influence the way people experience, express and manage pain
-Awareness of cultural differences of expression
-Avoid stereotyping.
-Recognize actual and potential influences of personal biases, attitudes, experiences, misconceptions and lack of information.
Vulnerable Populations for Pain to be Undertreated
-65 or older
-Racial and ethnic minorities
-Women
-Low health literacy, low english proficiency (recent immigrants)
-Lower income and level of education
-Older adults commonly fear negative consequences of analgesia (ie. addiction)
Obtaining information about pain
-Assess for pain during initial contact, at frequent intervals, when condition changes.
-Assess effectiveness of analgesic 30 to 60 minutes post-administration.
-“Gold standard”: self-report about pain
-Pain rating scales used to assess pain intensity
-Use open-ended questions to identify person’s expectation for relief.
Pain assessment tools
The Pain Assessment in Advanced Dementia
Pain Assessment Checklist for Seniors with Limited Ability to Communicate
Adjuvant analgesics
-medications that have a primary indication other than the treatment of pain, such as antidepressants or anticonvulsants, but relieve pain in some conditions.
-Adjuvants most often act on the modulation phase along the pain pathway by interfering with the reuptake of serotonin and norepinephrine, thereby inhibiting the transmission of nociceptive impulses
Health Assessment of Older Adults
-Manifestations of illness, even acute illness, tend to be less predictable in older adults than in younger adults.
-For any one manifestation of illness in an older adult, there are usually several possible explanations
-Cognitive impairments can make it difficult for older adults to accurately report or describe a physiologic problem and reliable sources of information may be scarce or inaccessible.
Lab Values that are NOT affected by Normal Aging
Hematocrit and hemoglobin
Electrolytes (sodium, potassium, chloride, bicarbonate)
Calcium
Phosphorus
Liver function tests
Blood urea nitrogen
Thyroid tests
White blood cell count
Platelet count
Lab Values that are often abnormal in older adults
Glucose
Albumin
Serum iron, iron-binding capacity, ferritin
Alkaline phosphatase
Try This: Best Practices in Nursing Care of Older Adults
-Cost-free web-based articles and videos
-Identify specific areas to address in care plan
-Identify conditions that affect health status, level of functioning and quality of life
RNAO (Registered Nurses’ Association of Ontario)
Best Practice Guidelines have been developed for “Screening for Delirium, Dementia and Depression in the Older Adult,” as well as “Caregiving Strategies for Older Adults with Delirium, Dementia and Depression,” “Prevention of Constipation in the Older Adult Population” and “Prevention of Falls and Fall Injuries in the Older Adult.”
NICE (The National Initiative for the Care of the Elderly)
provides tools for nurses for assessment of older clients pertaining to walking, elder abuse, driving cessation, mental health
SPICES
Sleep disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
SHOW ME
Shirt & shoes
Hike to bathroom
Organization
Walk through home in all areas needed for ADL/IADL, Medications
Eating and making meals
*Used to assess level of functioning
functional assessment
Measurement of person’s ability to fulfill responsibilities and perform self-care tasks
-In geriatric clinical settings, there is increasing emphasis on using functional assessments as a core component of function-focused care, which is a rehabilitative approach to preventing functional decline and improving an older adult’s level of functioning
-Use of open-ended questions
ADLs
bathing, dressing, mouth care, hair care, dietary intake, transfer mobility, ambulation, bed mobility and bladder and bowel elimination.
IADLs
shopping, laundry, transportation, housekeeping, meal preparation, money management, medication management and the use of telephone.
assess functioning in older adults with cognitive impairment
Cleveland scale for activities of daily living
function focused care
-previously referred to as restorative care
-Focus on evaluation capability in regard to functional and physical activity with interventions to optimize and maintain functional abilities and increase physical activities
-rehabilitative approach to preventing functional decline and improving an older adult’s level of functioning
Comprehensive geriatric assessment
medical
psychosocial
cognitive
functional components
minimum data set (MDS)
-standardized assessment form for nursing homes
-done on admission and every 3 months
-Primary purpose: to improve care and quality of life of older adults
Everyday competence
used to describe the effects of cultural, physical, cognitive, emotional, social and contextual factors on a person’s daily functioning
home assessments
-base for assessing relationship between the older adult and his or her environment
-Identify fall risks, safety, proper lighting and temperature regulation of environment.
Risks for unsafe driving
-Age-related changes: vision, musculoskeletal function, and central and autonomic nervous systems
-Medical conditions, cognitive impairment, functional limitations, medication use and alcohol consumption
-Concerns related to driving: night driving, safely changing lanes
Referrals for driving evaluation and recommendations
-Families likely to seek guidance to address safety
-Provide resources
-Driving evaluation programs
-Emphasize purpose: not to take away driving privileges but interventions to improve safety
-Recommendations: modification of vehicles to compensate physical limitations, participating in driving rehabilitation therapy, refraining or restricting driving, driving education programs, programs that provide transportation
Age related changes: Bones
-Increased bone resorption
-diminished calcium absorption
-increased serum parathyroid hormone
-impaired regulation of osteoblast activity
-impaired bone formation secondary to reduced osteoblast production
-fewer functional marrow cells
-decreased estrogen in women and testosterone in men
age related changes: Muscles
-Decreased size and number of muscle fibers
-loss of motor neurons
-replacement of muscle tissue by connective tissue
-deterioration of muscle cell membranes
-diminished protein synthesis
Sarcopenia
loss of muscle mass, strength and endurance; the overall effect of age related changes
age related changes: Joints and connective tissue
-Harmed by continued use and begin to show wear and tear during early adulthood
-Diminished viscosity of synovial fluid
-degeneration of collagen and elastin cells
-fragmentation of fibrous structures in connective tissue
-outgrowths of cartilaginous clusters
-formation of scar tissue and areas of calcification in joint capsules and connective tissue
-degenerative changes in articular cartilage
age related changes: nervous system
-Central and peripheral nervous system may be primary mechanism in diminished muscle function
-Altered visual abilities
-slower righting reflex
-impaired proprioception
-diminished vibratory and positioning sensations in lower extremities
-Body sway: measure of motion of the body while standing
Osteopenia and osteoporosis
-Loss of bone: age-related change
-Bone density: amount of minerals in bone
-osteoporosis: silent disease
-Fragility fracture: little to no trauma causes fracture cause of frail bones
risk factors for osteoporosis and fragility fractures
Age 65 or 70 or older for women and men
Family history
Inadequate calcium and vitamin D intake
Lack of weight-bearing activity
Hormonal changes with regard to estrogen in women
Small bones
Increased age
Tobacco use, cigarette smoking
Excessive alcohol consumption
Certain medications (corticosteroids, anticonvulsants, anti coagulants, chemo)
Pathological conditions (hyperparathyroidism, malabsorption, etc)
risk factors for falls
History of falls
Use of walking aids
Pathologic conditions and functional and cognitive impairments
Medication effects
Environmental factors
Physical restraints
Osteoarthritis
- degenerative inflammatory disease affecting joints and attached muscles, tendons and ligaments
-Characterized by pain, swelling and limited movement of joints
-Leading cause of disability
-Risk factors
-Trauma, genetics, obesity and age-related changes
-Focus: self-care health education interventions
Osteoarthritis: Nursing Focus
-Participating in aerobic, resistance, land-based and aquatic exercise programs that focus on improving musculoskeletal strength, balance and endurance (e.g., yoga, aquatherapy, tai chi)
-Avoiding high-impact activities
-Wearing good shock-absorbing shoes
-Balancing weight-bearing activities with rest periods
-Losing weight if appropriate
-Using orthotics, supports, braces and shoe inserts as appropriate
-Using canes, walkers and other assistive devices as appropriate to relieve weight-bearing joints, improve balance or achieve independent functioning
-Using moist heat and analgesics for pain
Timed Up and Go (TUG) Test
simple-to-use tool for assessing gait speed and balance
Promoting healthy musculoskeletal function
-improved functioning, increased bone strength and prevention of falls and disability, flexibility exercises, weight bearing exercise, moderate aerobic exercise
-Preventing falls and fall-related injuries
-Addressing intrinsic risk factors (gait and balance impairments; improving mobility)
-Addressing extrinsic risk factors (environmental conditions)
-Using monitoring devices in institutional settings
-Providing assistance in independent settings
-Addressing fear of falling
-Promoting caregiver wellness
-Implementing fall-prevention programs
Multimorbidity
multiple chronic conditions
Guiding principles
-Interventions should be holistic and based upon an understanding of the impact conditions have upon older adults’ physical and mental health and overall wellness.
-It is important to establish a continuum of integrated services that begins with preventative support and moves through to medical care.
-Interventions should be tailored toward the diversity of caregivers and their needs.
-Services and interventions need to improve the quality of life for individuals and families
Atypical presentation
-Signs and symptoms of disease differ from what is expected. (altered, subtle, absent or nonspecific)
-Especially common in cognitively impaired or older than 85 years
-Adverse effects of medications
Geriatric syndromes
-Refers to conditions that do not fit a specific disease category but have a significant negative effect on the older person’s level of functioning and quality of life.
-Ex: Falls, frailty, malnutrition, urinary incontinence, functional decline, pressure ulcers, cognitive impairment and delirium
-Highly prevalent and caused by the interplay among several risk factors and underlying conditions
-Diminish the person’s ability to adapt to stressors
-Associated with substantial morbidity and poor outcomes
frailty
Patients are considered frail when they have three or more of the following conditions:
-Low level of physical activity
-Slow walking speed
-unintentional weight loss (i.e., 4.5 kg or more during the past year)
-weakness (measured by diminished handgrip strength)
-Self-reported exhaustion
Serious negative consequences
-Increased mortality
-Admissions to hospitals and long-term care facilities
-Decreased functioning and quality of life
Connecting the Concepts of Wellness, Aging, and Illness
-Promoting personal responsibility for health through self-care measures and management of chronic conditions
-Challenge ageist attitudes
-Helping older adults identify personal strengths that are not dependent on their physical health
-Supporting and promoting interpersonal relationships
-identify realistic goals for q
-Facilitating the use of new resources and strengthening the support resources that already are in place
palliative care
an organized system for achieving best possible quality of life for patients and their family caregivers.
For persistent, life-threatening or recurring conditions that adversely affect daily functioning or will predictably reduce life expectancy (e.g., frailty, acute stroke, malignancies, dementia and other neurodegenerative conditions)
Goals are to prevent and relieve suffering and support best possible quality of life
Assist with decision making and provide opportunities for personal growth.
Ideally, palliative care is initiated early in the course of an illness, not just the end and at the same time as curative or disease-modifying treatments
Palliative services are provided within all hospice programs, they are also available outside of hospice programs, and they have a broader range of admission criteria
hospice vs palliative care
-Generally, recipients of hospice services must have a prognosis of living for 3 months or less and they agree to forego curative therapies.
-In contrast, palliative care can be provided at any point during the course of a chronic declining condition and concurrently with life-prolonging therapies or as a main focus of care for as long as the person has the serious illness.
Promoting Wellness for Older Adults with Cancer
Stop smoking
Maintain ideal body weight
Consume 5 servings of fresh fruit and veggies and 26-35g of fiber daily
Avoid excessive exposure to sunlight
Avoid excessive alcohol consumption
Promoting Wellness for Older Adults with Diabetes Mellitus
-Most common chronic condition
-Highest prevalence among Canadian Aboriginals
-Complicated by the common occurrence of multiple conditions
-Nursing assessment
-Wellness nursing diagnoses and wellness outcomes
-Nursing interventions
-Teaching about self management is the cornerstone
-Group interventions
Promoting Wellness for Older Adults with Heart Failure
-Leading cause of hospitalizations and readmissions; 57% of admission are potentially preventable with adequate self-care.
-Assess effects of other conditions, risk factors that can be addressed through health promotion
-focus on teaching about actions the person can take to achieve the best possible level of functioning and quality of life despite the chronic condition
-Teach about symptom recognition
What is Palliative Care?
Type of healthcare for patients and families living with, or at risk of developing a life threatening illness
Who Requires Palliative Care?
-ANY patient with a chronic illness who is experiencing a decreased quality of life
-Should be part of the treatment plan from the time of diagnosis through end of life and hospice care. That may be years in some cases
What is the Focus of Palliative Care?
Relieve suffering
Improve the quality of life for a client and his or her family
what is hospice care?
-A philosophy of care that seeks to support dignified dying for the person and their families and caregivers
-Hospice treats the person, not just the disease.
-It is offered to patients who are no longer receiving curative treatments for their illnesses, and want to focus ONLY on quality of life
-Patients with prognosis of six months or less, if the illness were to follow the usual course
-Eligibility criteria for hospice include physician referral and, generally, a patient prognosis of 6 months or less
When is Palliative Care Implemented?
-From the time of diagnosis of an illness through end of life.
-That may be years in some cases!
-When the disease has caused several damages and the death of a client is expected within the next few years. e.g. Cancer, COPD, CHF, Renal disease; and the patient has decided to focus on comfort measures rather than cure/treatment; DNR
-Implemented simultaneously with restorative care.
What is End-of-Life Care?
-Is the final stage of the palliative approach.
-When death is inevitable
-Short trajectory (months, days, hours)
-Focus on supporting client and family choices
when does end of life care begin
-Death has traditionally been defined as the cessation of all biologic functions.
-Major medical and technological developments have changed the perception of death from a clearly defined event to an evolving process.
-For example, a patient can be considered legally dead resulting from the absence of brain function, but not be clinically dead if medical technology has sustained heart and lung functioning.
-For many older adults, the end of life may be a gradual process.
-In many cases, a major medical event causes the older adult to transition from a state of chronic illness to an end-of-life state in which death occurs
three trajectories of death
-expected
-mixed
-unexpected
expected death trajectory
steep progressive decline, often measured in clinical benchmarks, with prolonged terminal phase
mixed death trajectory
initial successful treatment and period of stability, followed by steep decline and short terminal phase
unexpected death trajectory
slow decline (i.e., periodic exacerbations with recovery never reaching former level of health), followed by extremely short terminal phase
Views of Death and Dying in Western Culture
-Western culture tends to deny or ignore death.
-Despite prevalent attitudes and beliefs, acknowledgement and acceptance of death has been increasing, along with a focus on a more holistic view of end-of-life care. This change is due largely to the baby boom generation
Older Adults Perspectives on Death and Dying
-Older adults tend to be more aware and accepting of the inevitability of death
-Older adults who develop a holistic perspective recognize that old age can present opportunities for fulfillment and self-actualization
-Defining a “good death” for older adults is extremely personal and strongly influenced by one’s level of function, independence and quality of life.
-Although older adults may have an increased awareness of the inevitability of death, true acceptance of death is not a clearly defined process and even at the end of life
Medicalization of end-of-life care
-describes care that focuses on prolonging life through the use of medical technology rather than on interventions for comfort and quality of life.
-Major medical advances that began during the 20th century shifted the approach to end-of-life care.
-By the middle of the 20th century, health care facilities had become centres for curing disease and health care professionals viewed death as something to be avoided because it symbolized failure
-Prolonging life, even at the expense of quality, was viewed as the ultimate accomplishment: a symbol of success for patients, families and the health care teams involved.
legal and ethical concerns about MAID
-The person must make several requests for assisted suicide, with at least 15 days between first and last request.
-Two physicians must determine that the person is competent.
-Information must be provided about hospice, but there is no requirement that the person enrol in hospice.
-Physicians and institutions are not required to provide physician-assisted death
Promoting Wellness at The End of Life
-Being treated as an individual and with respect, including the proper use of his/her name
-Maintaining independence, while having basic care needs met
-Being involved in decision-making
-Having privacy and a safe environment
-Being listened to (including some socialization with care-giving staff) and having needs and wishes respected
-Experiencing good communication
-Feeling peaceful and ready to die
-Absence of anxiety and depressive mood
Myths and Misconceptions about Palliative Care
-All clients at End of Life must be on Palliative Care /Hospice Unit
-Palliative care is the same for all clients
-Only appropriate at very end of life
-Pain is expected part of aging
-Palliative care is only for clients with a cancer diagnosis
pronouncing death (expected death)
Physician may provide orders for a RN and/or RPN to pronounce an expected death
unexpected death
The physician must pronounce death when the death is unexpected
MAID
Where a person dies as a result of medical assistance in dying, the physician or nurse practitioner who provided the medical assistance in dying shall give notice of the death to a coroner and, if the coroner is of the opinion that the death ought to be investigated, the coroner shall investigate the circumstances of the death and if, as a result of the investigation, the coroner is of the opinion that an inquest ought to be held, the coroner shall hold an inquest upon the body.
To receive medical assistance in dying, a patient must:
-Be eligible for publicly funded health care services in Canada
-Be 18 years of age or older
-Be capable of making health care decisions
-Have a grievous and irremediable medical condition, which means the patient: Has a serious and incurable illness, disease or disability
-Is in an advanced state of irreversible decline in capability
-Is enduring physical or psychological suffering, caused by the medical condition or the state of decline, that is intolerable to the person
-Natural death has become reasonably foreseeable.
Signs and Symptoms of Death Within Days
Altered breathing patterns
Changing circulation
Decreased muscle tone
Decreased senses
End-of-Life Signs & Symptoms
Increase weakness, fatigue, temperature
Decreased intake of food and fluids, exercise - constipation
Difficulty swallowing-loss of gag reflux
Delirium/agitation
Respiratory changes, circulatory changes
Incontinence, retention
Fatigue (Asthenia)
Constipation
Dyspnea
Nausea & vomiting
Dehydration
Anorexia
autonomy
-Autonomy is the personal freedom to direct one’s own life as long as it does not infringe on the rights of others.
-Autonomous older adult: capable of rational thought and able to recognize the need for problem solving
-Loss of autonomy = loss of independence
competency
-Refers to the ability to fulfill one’s role and handle one’s affair in a responsible manner
-All adults are presumed to be competent for participating in legally binding decisions.
-Have right to make health-related decisions unless have been declared incompetent by a court of law
guardianship/conservatorship
-If a person is deemed incompetent, the judge assigns either partial or full guardianship/conservatorship to a designated person.
-Partial → incompetent person makes limited decisions
-Full → incompetent person loses all rights to decision making
decision making capacity
-A measure of older adult’s ability to make an informed, logical decision about an aspect of health care
-Clinical term: ability to understand, make, and be responsible for the consequences of health care decisions
Decision-making capacity requires
-Ability to understand, process information relevant to decision regarding diagnosis, prognosis and treatment options
-Ability to understand risks versus benefits and apply personal values
-Communicate decision to others
advance directives
-Advance medical directive: legal documents that allow competent older adults to document medical care they would or would not want to receive
-Advance directive documents must be drawn up when the person is capable of understanding their intent, and they become effective only when the person lacks the capacity to make a particular health-related decision.
-It may be prudent to periodically reassess decision-making abilities as the older adult’s condition changes.
Health care proxy/proxy decision maker
person responsible for communication of person’s wishes if they become unable or incompetent to communicate decisions of care (terms vary slightly among provinces/territories)
Durable Power of Attorney for Health Care
-Type of advanced directive
-Surrogate health care decision maker/health care proxy
-To represent the person during any time of incapacity
-Takes effect whenever someone cannot, for any reason, provide informed consent for health care treatment decisions.
-Must be initiated when the older adult is competent and takes effect ONLY when the person is incapacitated
Do Not Resuscitate (DNR) Orders
-Type of advanced directive
-DNR is a very specific type of advance directive that compels health care providers to refrain from CPR if there is no sign of breathing or no heartbeat.
-Do not mistake a DNR order to withhold other medical treatments!
-“Allow a natural death,” a preferred term to DNR terminology
living wills
-Living wills are a type of advance directive whose purpose is to guide decisions about care that is provided or withheld
usually at the end of life or when the person is considered terminally ill.
-People must be competent to initiate a living will and they can revoke or change it at any time as long as they remain competent.
-A limitation is that they do not cover all foreseeable options
-Applies only to situations where person is considered terminally ill
-Another limitation: definitions of terminal illness are not always clear, and there may be disagreement about whether the person is terminally ill.
-In general, someone is considered to be terminally ill when a physician determines that his or her predictable life expectancy is 6 months or less. Some laws or policies require that two physicians document that the person is terminally ill.
Medical Orders for Life-Sustaining Treatment
-Physician Orders for Life-Sustaining Treatment (POLST) directives: medical directives effective for ensuring that patient preferences are known and honored in all health care settings and situations
-POLST directives are used for people who have advanced chronic progressive illness and/or frailty, those who might die or lose decision-making capacity during the next year, and older adults who have a strong desire to further define their preferences of care
Physician Orders for Life-Sustaining Treatment (POLST) Directives
-In contrast to advance directives, which are initiated and completed by individuals to guide decisions about their care in the future, POLST documents are completed by health care professionals and serve as a medical order for providing or withholding treatment under any circumstances.
-The document was developed to translate advance directives into physicians’ orders that are followed by all clinicians whenever patients cannot speak for themselves. Thus, they apply to all immediate medical care providers, ranging from emergency medical providers to long-term care facilities, even if these health care professionals have not been involved with the development of the document.
-POLST documents usually are printed on brightly coloured forms and are transferred across settings.
Issues Specific to Long Term Care (LTC) Settings
-Quality of care has led to more emphasis on autonomy and individual rights.
-Nursing responsibility is to involve the older adults, families and surrogate decision makers in developing plans that are safe, individualized and respectful of the person’s preferences and everyday ethical issues
-Using restrictive measures to address potential risks to safety
-Restricting cigarette smoking
-Allowing residents to refuse therapies, social activities, and food or fluid
-Scheduling resident care practices for the convenience of the staff rather than according to individual preferences
Elder Abuse and Neglect
-Elder abuse/mistreatment is defined by intentional actions causing harm or create serious risk of harm, whether or not intended to vulnerable older adult by a caregiver or other person who stands in trust relationship, or failure by the caregiver to satisfy older adult’s basic needs or protect from harm.
-The typical reported elder abuse victim is a socially isolated and physically or cognitively impaired woman of advanced age who lives alone or with the abuser and depends on the abuser for care.
Common psychosocial risk factors for elder abuse
impaired cognition and long-term mental illness
Invisibility and Vulnerability
-Vast majority of cases go unreported.
-Social, personal, situational and environmental factors associated with vulnerability
-Older adults may have less contact with the outside world.
-Older adults reluctant to admit to abuse/neglect
-Significant psychosocial limitations due to dementia, depression and mental health issues
-Absence of close relatives and other support persons able or willing to provide adequate assistance
Administrative problems within institutions
-Lack of abuse prevention policies
-Insufficient staff screening
-Inadequate staff education and training
-Staff shortages and turnover
Functional Consequences Associated with Elder Abuse and Neglect
-Physical abuse: inflicting and threatening to inflict physical pain or injury or depriving of a basic need
-Sexual abuse: nonconsensual sexual contact of any kind, coercing to witness sexual behavior
-Emotional/psychological abuse: inflicting mental pain, anguish and distress through verbal or nonverbal acts
-Financial exploitation: illegal taking, misuse, concealment of funds, property or assets
-Neglect: refusal, failure to provide food, shelter, health care or protection
-Abandonment: desertion by anyone who assumed responsibility for care
-Self-neglect: threats to his or her own health or safety
Nursing Interventions to Address Elder Abuse and Neglect
-Interventions involve legal actions when decision-making abilities are impaired.
-Interventions in institutional settings
-Interventions in community settings
-Interventions in interdisciplinary teams
-Facilitating referrals
-Prevention and treatment interventions
Legal Interventions and Ethical Issues
-Voluntary and involuntary legal interventions
-Competency of a person to make decisions
-Adult protective services legislation is limited.
-Ethical issues: principles of adult protective services
-Ethical questions and suggested solutions
-In most provinces/territories, reporting suspected abuse is mandatory for health professionals
Adult Protective Services (APS)
-Provide protection for a person who is abused
-No federal guidelines or specific funding
-Services differ among the provinces and territories.
-Facilitating identification of abuse and neglect
-Most states protect confidentiality of reports.
-In some jurisdictions, failure to report has penalty.
-APS have primary responsibility for implementing elder abuse laws; nurses have essential roles.
