Ethico-Legal Considerations for Communicating with Older Persons (PDF)

Ethico-Legal Consideration Communicating with Older Persons Geriatric Health Care Team  Learning Outcomes: At the end of the lesson; the students can: 1.Identify the Ethical principles, dilemmas and practices in the care of the elderly. 2.Describe the communication skills and techniques...

Ethico-Legal Consideration Communicating with Older Persons Geriatric Health Care Team  Learning Outcomes: At the end of the lesson; the students can: 1.Identify the Ethical principles, dilemmas and practices in the care of the elderly. 2.Describe the communication skills and techniques use as part of the healing process.  Learning Outcomes: At the end of the lesson; the students can: 3. Explain the roles of the Geriatric health team in holistic care.  Ethics is a fundamental part of geriatrics that refers to a framework or guideline for determining what is morally good or bad. Ethical problems arise when there is conflict about what is the “right” thing to do. Being able to communicate effectively is one of the most important life skills. Those with good interpersonal skills are strong verbal and non-verbal communicators and are often considered to be “good with people.” Therefore, knowing what is the right thing to do and how to properly communicate not only to the patient but also to the entire health care team allows nurses to deliver safe and quality care. T H E L I V E D E X P E R I E N C E When I was growing up life was hard. We were so poor we couldn’t do much but to hold on tight. When I was lucky I could get work plowing a field and make $1.00 an acre. You work hard, and you make do. There were not such things as going to a doctor or a hospital, you just did the best you could do and pray you don’t get sick. Then when I turned 65 I got a little check from the government and a red, white, and blue insurance card. The check isn’t much, only about $564 a month, but you know I just consider myself blessed and better off than ever before. And now I don’t worry about my health, I will be taken care of. Aida, age 74  Ethico-legal Considerations in the Care of Older Adult The key legal considerations center on - consent - standard of care - supervision Care for the aged resembles healthcare in some respects: - respect for autonomy - beneficence (acting for the good of the patient) - nonmaleficence (avoiding harm) - justice (treating people alike) A. Laws affecting Senior Citizens / Older Persons (RA 7432, RA 9257, RA 9994) Expanded Senior Citizens Act of 2010 h t t p s ://www. o ffi cia lg azette.go v.p h/201 0/02/15 /repu bl ic -a ct-no-9 994 / REPUBLIC ACT NO. 9994 An act granting additional benefits and privileges to senior citizens, further amending republic act no. 7432, as amended, otherwise known as “an act to maximize the contribution of senior citizens to nation building, grant benefits and special privileges and for other purposes” A. Laws affecting Senior Citizens / Older Persons National policy on Older People REPUBLIC ACT NO. 334 The Accessibility Law of 1982 provides for a minimum requirements and standards to make buildings, facilities and utilities for public use accessible to persons with disability, including older persons who are confined to wheelchairs and those who have difficulty in walking or climbing stairs. A. Laws affecting Senior Citizens / Older Persons An Act Establishing a Senior Citizens Center in all Cities REPUBLIC ACT NO. 7876 “Includes municipalities in the Philippines and Appropriating Funds Therefore” provides for establishment of Senior Citizens Centers to cater to older persons’ socialization and interaction need as well as to serve as a venue for the conduct of other meaningful activities. A. Laws affecting Senior Citizens / Older Persons Presidential Proclamations and Executive Orders Presidential Proclamation No.470 Series of 1994, declaring the first Week of October of every year as “Elderly Filipino Week." A. Laws affecting Senior Citizens / Older Persons Presidential Proclamations and Executive Orders Executive Order No.105, Series of 2003, approved and directed the implementation of the program providing for group homes and foster homes for neglected, abandoned, abused, detached and poor older persons and persons with disabilities. B. Medications of Older Adults Polypharmacy - the use of multiple medications. There is no standardized threshold to define what constitutes “multiple medications”; however, a threshold of at least five medications is commonly accepted. C. Ethical Principles / Dilemmas Legal Issues in Gerontological Nursing Basic knowledge of the most common legal issues that may arise when working with older adults is as important as the financial issues. Legal concerns are most often related to an individual’s ability to make health care decisions and consent to treatment or research. C. Ethical Principles / Dilemmas Competence and capacity are interchangeable legal terms used to indicate the level of a person’s ability to make decisions. - includes the ability to understand the consequences of one’s actions and choices. - ability is presumed unless there is clear evidence indicating that the person cannot understand the information needed to make decisions. C. Ethical Principles / Dilemmas Power of attorney (POA) is a legal document in which one person designates another person (e.g., family member, friend) to act on his or her behalf. Guardians and conservators are individuals, agencies, or corporations that have been appointed by the court to have care, custody, and control of a disabled person and manage his or her personal or financial affairs (or both) when the person has been found (adjudicated) to lack capacity. C. Ethical Principles / Dilemmas Elder Mistreatment and Neglect A person in need of the assistance of others is at risk for harm and injury at the hands of a frustrated, angry, fraudulent, careless, or disturbed caregiver. Mistreatment of older frail and vulnerable adults is found in all socioeconomic, racial, and ethnic groups. D. Long-Term Care - involves a variety of services designed to meet a person's health or personal care needs during a short or long period of time. These services help people live as independently and safely as possible when they can no longer perform everyday activities on their own. Long-term care is provided in different places by different caregivers, depending on a person's needs. Most long-term care is provided at home by unpaid family members and friends. It can also be given in a facility such as a nursing home or in the community, for example, in an adult day care center. E. Palliative Care - is specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the elderly and the family. provided by a specially-trained team of doctors, nurses and other specialists who work together with a patient’s other doctors to provide an extra layer of support. Palliative care is based on the needs of the patient, not on the patient’s prognosis. It is appropriate at any age and at any stage in a serious illness, and it can be provided along with curative treatment. F. Advance Directive - is a legal document - tells the doctor and family what kind of medical care an old person wants to have if he/she can’t tell them him/herself. This could happen if the elderly is: in a coma seriously injured terminally ill have severe dementia F. Advance Directive A Do Not Resuscitate (DNR) order can also be part of an advance directive. Hospital staff try to help any patient whose heart has stopped or who has stopped breathing. They do this with cardiopulmonary resuscitation (CPR). A DNR is a request not to have CPR if the heart stops or the patient stops breathing. The doctor will put the DNR order in the medical chart. G. End of Life Care Loss, dying, and death are universal, incontestable events of the human experience. Some loss is associated with the normal changes with aging, such as the loss of flexibility in the joints. Some is related to the normal changes in everyday life and life transitions, such as moving and retirement. One goal of intervention is to assist the individual (or family) in attaining a healthy adjustment to the loss experience and reestablishing equilibrium. Memories are reframed so that they can account for the loss without diminishing the value of that which has been lost thus minimizing the risk for complicated grief. G. End of Life Care When elders are in crisis, begin with the gentle establishment of rapport. Nurses introduce themselves, explain the nature of their roles (e.g., charge nurse, staff nurse, medication nurse) and the time available. Provide support and a safe environment and ensure that basic needs , such as meals, are met. The nurse can soften the despair by fostering reasonable hope , such as, “You will make it through this time, one moment at a time, and I will be here to help.” Nurses observe for functional disruption and offer support and direction. They may have to help the family figure out what has to be done immediately and find ways to do it. G. End of Life Care As grievers search for meaning, nurses may need help in finding what they are looking for if this is possible. Sometimes it is information about a disease, a situation, or a person. Sometimes it is a spiritual search and help in finding a source of comfort such as a priest, rabbi, or medicine person or a place of peace, such as the chapel or mosque. H. Spirituality among Older Persons Spirituality is as a “quality of a person derived from the social and cultural environment that involves faith, a search for meaning, a sense of connection with others, and a transcendence of self, resulting in a sense of inner peace and well-being.” The spiritual aspect of people’s lives transcends the physical and psychosocial to reach the deepest individual capacity for love, hope, and meaning. H. Spirituality among Older Persons As people age and move closer to death, spirituality may become more important. Declining physical health, loss of loved ones, and a realization that life’s end may be near often challenge older people to reflect on the meaning of their lives. Spiritual belief and practices often play a central role in helping older adults cope with life challenges and are a strength in the lives of older adults. Distinguishing between religion and spirituality is a concern for many health professionals. Religious beliefs and participation in religious obligations and rites are often the avenues of spiritual expression, but they are not necessarily interchangeable. “Religion can be described as a social institution that unites people in a faith in God, a higher power, and in common rituals and worshipful acts. Each religion involves a particular set of beliefs Communicating with Older Persons A. Information Sharing Privacy refers to the right of an individual to keep his or her health information private. Confidentiality refers to the duty of anyone entrusted with health information to keep that information private. B. Formal or Therapeutic Communication B. Formal or Therapeutic Communication Attentive, Active Listening is an essential part of communication. It is far more than hearing and simply remaining silent while listening to words. Active attentive listening is not a passive activity; it entails the nurse's hearing, processing and purposefully comprehending the client's words, as well as processing these words in the context of the client's situation and the nonverbal communication that is sent by the client as they are verbally expressing some message to the nurse. B. Formal or Therapeutic Communication Silence is a purposeful active process rather than a passive process. Senders and receivers of the message take advantage of brief pauses of silence to think about and reflect on the full meaning of received message and to contemplate and reflect on how to respond to the sent message with feedback. Silence is a therapeutic communication technique that is also very helpful when the nurse wants to give the client ample time to fully and openly discuss their feelings, opinions and beliefs, however, prolonged silence may be interpreted by the client as a lack of interest on the part of the nurse so silence, in order to remain therapeutic, must be of an appropriate duration so that it does not adversely affect the client and the therapeutic nurse-client relationship. B. Formal or Therapeutic Communication Focusing with the client is a therapeutic communication technique used by nurses, and other members of the health care team, that facilitates the client 's abilities to focus on and pay attention to the matters at hand, which should reflect the client 's priorities. Some clients may use the nurse's presence to talk about things not even related to their health care and their health care problems. For example, they may want to chat about their extended family and their accomplishments at the same time that the nurse has to educate the client about their plan of care. Focusing on the subject at hand decreases the risk of having these kinds of distractions impair the therapeutic communication process. For example, the nurse may say, "Mrs. Jones, your family is very interesting and successful. Thank you for sharing this information with me. Now, let 's discuss your diabetes and the insulin that you will be taking after you leave the hospital". B. Formal or Therapeutic Communication Using Open Ended Questions elicits more and fuller information than a closed ended question that requires more than a simple yes or no answer. This therapeutic communication technique is particularly useful when the nurse wants fuller and deeper information from the client and when the nurse is facilitating the client's full and free ventilation and expressions of their own feelings and beliefs. Closed ended questions are also useful particularly when the client is not able to, for one reason or another, formulate more complete feedback and communication to the nurse. For example, closed ended questions are useful when the client is cognitively impaired or they are on mechanical ventilation with intubation and not able to speak with the nurse and others. B. Formal or Therapeutic Communication Clarification - Messages are often clarified and validated with clients in order for the nurse to insure that the nurse has received and interpreted the complete and correct message without any errors, without any bias and without any false assumptions. Specific clarification techniques include exploring, paraphrasing, reflecting and restating, which will be discussed below. A possible question that the nurse may ask the client to clarify a message could be "Am I correct that you told me that you plan on having home health care after your discharge?" or "You appear upset. Would you like to talk about it?' when the client appears upset with their nonverbal facial cues. B. Formal or Therapeutic Communication Exploring in contrast to invasive and non therapeutic probing, is using techniques that encourage the client to provide more details and information about a particular topic or health care problem. B. Formal or Therapeutic Communication Paraphrasing is used to clarify a client's message, is used by the nurse to rephrase a client's comment or question in a manner that is similar to what the nurse thinks that they have heard and understood. For example, a nurse may paraphrase a client statement such as "I am too tired to even think" with, "Did you mean that you are too tired now to continue with this education?" B. Formal or Therapeutic Communication Restating is done to clarify the client's message by repeating the same statement back to the client. For example, when a client says, "I am ready to do some walking" and the nurse says, "Did I hear you say that you are now ready to do some walking?" B. Formal or Therapeutic Communication Reflection a technique that reflects and mirrors what the nurse believes the client's feelings to be underneath the words. It mirrors, or reflects, the patient's feelings, not words, back to the client so that the client's feelings can be further explored and expressed by the patient. For example, when a client appears to be angry and upset, the nurse may state, "You seem a little angry today. Would you like to talk about it?". B. Formal or Therapeutic Communication Providing Leads to the Patient enables the client to continue discussing things with the nurse and it also facilitates the client's beginning a new discussion that is focused on a particular thing. For example, the nurse may say, "Tell me about your concerns relating to your new medications". Hopefully, the client will take this lead and begin a discussion about their new medications and their concerns relating to them with the nurse. B. Formal or Therapeutic Communication Summarizing is a highly useful therapeutic communication technique that sums up the primary and main points that were discussed as well as the conclusion of the discussion that was mutually decided up. For example, a nurse who is educating the client and family members about diabetes management and the interactions of diabetic medications, exercise, diet and other factors may summarize this discussion with a summarizing statement such as, "During our discussion today, we have discussed the roles of diabetic medications, exercise, diet and other factors as they interact with each other and how these interactions impact on the successful management of diabetes." B. Formal or Therapeutic Communication Recognition, Acknowledgment and Acceptance of the client and their thoughts which are conveyed during communication are therapeutic communication techniques and strategies that give the nurse the opportunity to let the client know that you are interested in them and respectful of them and their thoughts It also allows the client to recognize that the nurse is open, honest and without any bias or judgements. The nurse accepts the client regardless of their thoughts and words. B. Formal or Therapeutic Communication Offering of Self - therapeutic communication process and the therapeutic nurse-client relationship must be based on the nurse's willing and unconditional offering of self and their time to the client and their needs with only limited self disclosure by the nurse that directly assists the client with meeting their needs. C. Informal or Social Communication Informal communications include speaking to a person about the weather, writing an email about your holiday, sending a birthday card or talking to someone at the grocery shop. Informal communications can also be gestures (with no words). Informal communication in the workplace is often called 'the grapevine'. D. Non-verbal Communication ✓ Facial expressions - the human face is extremely expressive, able to convey countless emotions without saying a word ✓ Body movement and posture ✓ Gestures ✓ Eye contact ✓ Touch E. Acceptance, Dignity and Respect in Communication Treat patients with Dignity ✓ Listen to his/her concerns. ✓ Ask for opinions and let him/her know they are important to you. ✓ Involve in as many decisions as possible. ✓ Include in the conversation. Don't talk about him/her as though he's not there. ✓ Speak to him/her as an adult, even if you're not sure how much he understands. F. Barriers to Communication Challenging is forcing the client to defend and justify their opinions, beliefs, and feelings. Challenging shows a lack of respect for the client and a lack of acceptance of the client as a unique being who has, and is entitled to, their own beliefs and opinions. The client has valid feelings that should never be challenged by the nurse. F. Barriers to Communication Probing is also not therapeutic. It is invasive, uncomfortable for most clients, and a threat to the client's right to privacy and confidentiality. Probing the client with questions that are not relevant to their health care and health related concerns is never appropriate. It may satisfy the nurse's curiosity but it is NOT at all helpful to the client and addressing the client's needs. F. Barriers to Communication Changing the Subject serves only the needs of the nurse and not the client, therefore, it too is not acceptable in nursing practice. People, including nurses, change the subject when they are too uncomfortable and uneasy about continuing the conversation. The conversation has become too stressful for the nurse. This is not an option. Nurses must identify their own feelings and cope with them before they enter into therapeutic conversations and relationships with clients. F. Barriers to Communication Defensiveness occurs when the nurse feels the need to defend themselves, their actions, their employers or others for their failures and shortcomings. Again, this technique fulfils the needs of the nurse rather than the client and, as such, it is not therapeutic. F. Barriers to Communication False Reassurances like trite comments and giving clients every day advice, are not at all therapeutic. False assurances and reassurances such as "Don't worry, you are in good hands" and "Everything will be fine" are examples of false reassurances that will certainly be a conversation stopper that will lead to client anxiety and the client's unwillingness to share their true thoughts and fears to the nurse in the future. These effects are detrimental to the client and their wellbeing as well as the therapeutic nurse-client interactions at the present time and also in the future. F. Barriers to Communication Disagreeing with clients is also not therapeutic or acceptable. The nurse can attempt to correct misinformation in a therapeutic manner but they should never disagree or argue with the client, their feelings and/or opinions. F. Barriers to Communication Judgments place a positive or negative value on the client and their messages. The therapeutic nurse-client relationship must be, at all times, nonjudgmental, open and honest. F. Barriers to Communication Rejection and Minimization - Rejection of the client and any minimization and rejection of their expressions of feelings and thoughts are also not at all acceptable in the therapeutic nurse - client relationship. F. Barriers to Communication Stereotyping is a barrier to effective communication and, in fact, it is a barrier to all thought and interpersonal relationships. Stereotyping involves generalized thoughts and words that are not at all based on the individuality and uniqueness of the individual. Geriatric Health Care Team A. Gerontologist / Geriatrician Gerontologists are responsible for educating other health professionals, community practitioners, as well as the community at large about the process of aging and how to age well by giving informative presentations, publishing books and articles about aging and health. A geriatrician is a doctor who specializes in care of the elderly and the diseases that affect them. The approach tends to be holistic and involves a multidisciplinary team. The geriatrician concentrates on managing the medical conditions affecting the patient. B. Nurse Gerontologist A geriatric nurse or gerontological nurse helps care for aging and elderly individuals. They are trained to be able perform traditional nursing duties, yet they also have special training that helps them better understand the special needs of many elderly people. C. Occupational Therapists Occupational Therapists treat injured, ill, or disabled patients through the therapeutic use of everyday activities. They help these patients develop, recover, improve, as well as maintain the skills needed for daily living and working. D. Physical Therapists Physical Therapists evaluate and record a patient's progress. Help the injured or ill people improve movement and manage pain. They are often an important part of preventive care, rehabilitation, and treatment for patients with chronic conditions, illnesses, or injuries. E. Speech and Language Therapists (SLT) Speech and Language Therapists (SLT) are highly trained professionals who assess and treat children and adults who are having difficulties with speech or language, as well as problems with communication, eating, drinking, and swallowing. F. Case Manager Case Manager are registered nurses tasked with the evaluation and implementation of health care plans for individual patients. They are concerned with providing effective and efficient medical care while managing the costs of treatment. Assess new patients. Update and revise patient health care plans as needed. G. Family / Significant others H. Nursing and Interdisciplinary Care; Conference Team Interdisciplinary Care Team (ICT) is a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient. Whenever possible the patient and the patient's family should be part of the team.