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Chapter3LegalandEthicalissues1.pptxGerontologic nursing
Chapter 3: Legal and Ethical Issues
Professional Standards
Health care providers have a general obligation to live up to accepted or customary standards of care
Federal and state statutes require nursing facilities to have written health care and safety policies
Sources of Law
Statutes are laws created by legislation and are enacted at the federal and state level
Health Insurance Portability and Accountability Act of 1996 (HIPAA)
In some states failure by clinicians to report suspected incidents of mistreatment is a misdemeanor punishable by fine or penalty
Sources of Law
HIPAA
Health Insurance Portability and Accountability Act
1996
Increase a person’s ability to get health care coverage when the person begins a new job
Help maintain continuous health coverage when a change of job occurs
Limits the use of preexisting conditions
Sources of Law
Every state in America has mechanisms for reporting elder mistreatment
Adult Protective Services (APS) programs exist in each state
Standards of care for nursing homes are based on policy stipulated in the Nursing Home Reform Act of 1987 (Omnibus Budget Reconciliation Act, 1987)
Many states currently have mandatory reporting laws for elder mistreatment in which nurses & health care practitioners are required by law to report suspected cases
Elder Abuse
Categories of Elder Mistreatment
3 basic categories of elder mistreatment
Domestic treatment - older persons home – by child, spouse, In-law)
Institutional mistreatment – contractual arrangement & suffer abuse - LTC facilities, assisted living, rehabilitation or hospital
Self neglect or self abuse – are mentally competent enough to understand the consequences of their own decisions – that threaten their own safety
Institutional Mistreatment
The types of mistreatment that occur in nursing homes likely mirror those in domestic settings
Physical abuse
Sexual abuse
Neglect
Financial abuse
Psychological abuse
Researchers have also speculated that shortages of staff, inadequate training of staff & staff burnout may be precipitating factors in mistreatment of nursing home residents
Institutional Mistreatment
Delay in reporting incidents
Residents afraid of retribution
Family members may fear having to find a new nursing home
Staff may fear losing their jobs
Facing recrimination by other staff members
Want to avoid adverse publicity
Assessment
Ideally the older adult and any suspected abuser should be interviewed separately
Maintaining a nonjudgmental approach will enable the nurse to obtain more accurate data
The physical symptoms of elder mistreatment are often difficult for clinicians to discern because older adults may suffer from chronic and acute illness that mask or mimic the presence of mistreatment
Assessment
Their self reporting may be questioned for accuracy or they may be unable to express the mistreatment situation due to
Amnesia
Aphasia – total or partial loss of ability to speak or understand language
Agnosia – inability to recognize common people and things
Apraxia – inability to perform simple task
It is often difficult to determine whether the older adult’s worsening physical condition is a result of the natural progression of illness or mistreatment
Because some frail older individuals are prone to underlying conditions that give rise to trauma, such as instability of poor gait and poor vision resulting in falls, it may be difficult to differentiate accidental from willful injuries
Types of Elder Mistreatment
Physical abuse
Psychological / emotional abuse
Sexual abuse
Financial exploitation
Caregiver neglect
Self neglect
Abandonment
Institutional mistreatment
Physical Abuse
Intentional infliction of physical injury or pain
Hitting
Shaking
Pushing
Improper use of physical
restraints
Signs & symptoms
Bruises
Black eye
Bone fractures
Injuries in various stages of healing
Reports of being hit or mistreated
Psychological / Emotional Abuse
Infliction of anguish, pain or distress
Yelling / verbal attacks
Swearing
Name calling
Belittling
Signs & symptoms
Emotional upset
Agitation
Extreme with drawl
Sexual Abuse
Any form of nonconsensual sexual intimacy
Rape
Molestation
Sexual harassment
Signs & symptoms
Genital bruising
Unexplained sexually transmitted disease
Financial Exploitation
Taking advantage of an older person for monetary or personal benefit
Unexplained monetary expenditures
Lack of money for personal necessities
Theft
Fraud
Signs & symptoms
Unexplained inability to pay bills
Inability to purchase necessity items such as food
Caregiver Neglect
Intentional (active) or unintentional (passive) failure to meet needs necessary for elder’s physical & mental well being
Failure to provide adequate food, clothing, shelter, medical care, hygiene or social stimulation
Signs & symptoms
Dehydration
Malnutrition
Unattended or untreated health problems
Listlessness
Decubitus ulcers
Urine burns
History of being left alone
Self Neglect
Personal disregard or inability to perform self care
Poor hygiene
Unkempt home environment
Signs & symptoms
Malnutrition
Fungal skin & nail infection
Insect & rodent infestation in the home
Abandonment
Desertion or willful forsaking of an elder
Dropping off an elder adult in the emergency department
Desertion
Signs & symptoms
An older adult left inappropriately alone
Institutional Mistreatment
When older adult has a contractual arrangement & suffers abuse or neglect
May be any combination of the afore mentioned
Signs & symptoms
Can be any of the signs & symptoms of the other examples of abuse
Characteristics of Older Adults at Risk
Difficult to obtain
Several characteristics are more common among victims
Sex
Age
Race
Low socioeconomic status
Low educational levels
Impaired functional or cognitive status
History of domestic violence
Stressful events
Depression
Interventions
Health care workers must be aware of local elder mistreatment reporting laws in their state
Many states have mandatory reporting laws & health care professionals must report suspected cases
In cases were abuse is suspected an older adult may benefit from a hospital admission to allow the healthcare team to carefully assess & formulate a plan of care
Documentation
Excellent documentation is extremely important in elder mistreatment cases
Objective documentation
Unbiased manner
Physical indicators that are clearly documented will assist in discussing & planning goals
Photo documentation is especially warranted in cases where there is evidence of physical or sexual abuse
Residents Bill of Rights
Most facilities have developed a contract for new residents to sign at the time of admission
Called admission agreement
This agreement sets forth the rights, obligations and expectations of each party
It is a way to inform residents of a facility’s rules, regulations and philosophy of care
See Box 3 – 1 on page 37 “Residents Bill of Rights”
Unnecessary Drug Use & Chemical & Physical Restraints
The OBRA requires that nursing facility residents be free of unnecessary drugs of all types, chemical restraints and physical restraints
Chemical restraints
Drugs that are used to limit or inhibit specific behaviors or movements
Physical restraints
Are appliances that inhibit free physical movement
Limb, vest, waist
Wheelchairs, geriatric chairs & side rails may also be restraints
Unnecessary Drug Use & Chemical & Physical Restraints
The nurse must carefully document the behavior or condition that led to the order for a restraint
Residents receiving antipsychotic drugs must have an indication for the use of the drug
Reasons must be documented in the physician’s order and chart / care plan
Advanced Medical Directives
Documents that permit people to set forth in writing their wishes and preferences regarding health care
Used to indicate their decisions if the time should come when they are unable to speak for themselves
An advance directive is not operative until the patient is no longer capable of decision making
Living Wills
Are intended to provide written expressions of a patient’s wishes regarding the use of medical treatments in the event of a terminal illness or condition
The patient’s wishes regarding the withholding or with drawl of life support
Living Will
Not effective until:
The attending physician has the document and the patient has been determined to be incompetent
The physician has determined the patient has a terminal condition or a condition such that any therapy provided would only prolong dying
The physician has written the appropriate orders in the medical record
Durable or General Power of Attorney
May designate someone else to make health care decisions at a time in the future when they may be rendered incompetent
The role of the designated surrogate in this situation is to make the decisions that most closely align with the patient’s wishes, desires and values
Conflicts
Families may disagree with the directives of a family member
Often family members express the desire to have more care than is requested by a patient
The law upholds the expressed desires of a patient over those of the family
But families may try to exert influence to bring about a decision that is sometimes contrary to the patient’s expressed wishes
POLST
Physician Orders for Life Sustaining Treatment
Process of communicating health care wishes during a medical crisis or decline in health
Include:
Cardiopulmonary resuscitation (CPR)
Medical interventions
Artificially administered nutrition
See Table 3.1 on page 42
See Figure 3.2 on page 42
PSDA
Patient Self-Determination Act
Came into effect 12/1/1991
To ensure that patients are given information about the extent to which their rights are protected under state law
Requires hospitals, nursing facilities and other health care providers who receive federal funds such as Medicare or Medicaid to give patients written information explaining their legal options for refusing or accepting treatment should they become incapacitated
