NCM-114-Module-2-Handouts.docx

College of Nursing, Nutrition and Dietetics Nursing Program NCM 114 -- Care of the Older Adults Module 2: Ethical, Pastoral, and Legal Considerations in the Care of Older Persons **[ETHICAL CONSIDERATIONS IN THE CARE OF OLDER PERSONS]** - What is Standard of Care? - A guideline for nursing...

College of Nursing, Nutrition and Dietetics Nursing Program NCM 114 -- Care of the Older Adults Module 2: Ethical, Pastoral, and Legal Considerations in the Care of Older Persons **[ETHICAL CONSIDERATIONS IN THE CARE OF OLDER PERSONS]** - What is Standard of Care? - A guideline for nursing practice and establishes an expectation for the nurse to provide safe, effective, and appropriate care. - It is used to evaluate whether care administered to patients meets the appropriate level of skill and diligence that can reasonably be expected, given the nurse's level of skill, education, and experience. - What is Autonomy? - Greek *autos* » self; *nomos* » governance - It involves self-determination and freedom to choose and implement one's decision, free from deceit, duress, constraint, or coercion. » **intellect and will** - Restrictions on autonomy may occur when there is potential harm to others such as communicable diseases or acts of violence. - **Therapeutic privilege** is the legal exception to the rule of informed consent, which allows the caregiver to proceed with the care in case of emergency, incompetence, waiver, or implied consent. - Client's Rights - The client rights document, also called the **patient's bill of rights,** reflects an acknowledgment of the client's right to participate in their health care with an emphasis on client autonomy. - The document provides a list of the rights of the client and responsibilities that the hospital cannot violate. - The client's rights affect the relationship between the client and health care provider and between the client and health care delivery system and protect the client's ability to determine the level and type of care received. - Patient's Rights when Hospitalized: 1. Right to considerate and respectful care. 2. Right to be informed about illness, possible treatments, and likely outcome, and to discuss this information with the physician. 3. Right to know the names and roles of the persons who are involved in care. 4. Right to consent or refuse treatment. 5. Right to have an advance directive. 6. Right to privacy. 7. Right to expect that medical records are confidential. 8. Right to review the medical record and to have the information explained. 9. Right to expect that the hospital will provide necessary health services. 10. Right to know if the hospital has relationships with outside parties that may influence treatment or care. 11. Right to consent or refuse to take part in research. 12. Right to be told of realistic care alternatives when hospital care is no longer appropriate. 13. Right to know about hospital rules that affect treatment and about charges and payment methods. - Rights for the Mentally Ill: 1. Right to be treated with dignity and respect. 2. Right to communicate with persons outside the hospital. 3. Right to keep clothing and personal effects with them. 4. Right to religious freedom. 5. Right to be employed. 6. Right to manage property. 7. Right to execute wills. 8. Right to enter into contractual agreements. 9. Right to make purchases. 10. Right to education. 11. Right to an independent psychiatric examination. 12. Right to civil service status, including the right to vote. 13. Right to retain licenses, privileges, or permits. 14. Right to sue or be sued. 15. Right to marry or divorce. 16. Right to treatment in the least restrictive setting. 17. Right not to be subject to unnecessary restraints. 18. Right to privacy and confidentiality. 19. Right to informed consent. 20. Right to treatment and to refuse treatment. 21. Right to refuse participation in experimental treatments or research. - Informed Consent - Informed consent indicates the client's participation in the decision regarding health care. - A consent must be signed freely by the client without threat or pressure and must be witnessed by another adult. - Legally, the client must be mentally and emotionally competent to give consent. - If a client is declared mentally or emotionally incompetent, the next of kin, appointed guardian (appointed by the court), or the durable power of attorney has legal authority to give consent. - When a nurse is involved in the informed consent process, the nurse is witnessing only the signature of the client on the informed consent form. - Mentally or emotionally incompetent Clients 1. Declared incompetent 2. Unconscious 3. Under the influence of alcohol or drugs 4. Chronic dementia or other mental deficiency - What is Confidentiality? - The principle that binds the practitioner to hold in strict confidence those things learned about a patient in the course of medical practice. - Clients have a right to privacy in the health care system. - A special relationship exists between the client and nurse, in which information discussed will not be shared with a third party who is not involved in the client's care directly. - Nurses' Responsibility: 1. Nurses are bound to protect client confidentiality by most nurse practice acts, by ethical principles and standards, and by institutional and agency policies and procedures. 2. Disclosure of confidential information exposes the nurse to liability for invasion of the client's privacy. 3. The nurse needs to protect the client from indiscriminate disclosure of health care information that may cause harm. - Maintenance of Confidentiality 1. Not discussing client issues with other clients or uninvolved staff in the client's care. 2. Not sharing health care information with others without the client's consent (including family members or friends of the client). 3. Keeping all information about a client private and not revealing it to someone not directly involved in care. 4. Sharing client information only in private and secluded areas. 5. Protecting the medical record from all unauthorized readers. - What is Veracity? - Truth-telling. The practice of health care is best served in the relationship of trust in which practitioner and patient are bound to the truth. - What is Fidelity? - The duty to do what one has promised. - What is Justice? - Three (3) essential properties of Justice: 1. Justice always refers **to another person**. Strictly speaking, there are no obligations of justice toward oneself. 2. The object of justice is not a free gift, but something that is **strictly due**. 3. Justice does not demand an approximate compensation, but only what is **exactly** **due**, neither more nor less. - Subjective parts of Justice (Division according to Aristotle and St. Thomas) -- the proper way to classify virtues is **according to their primary end**, not according to the persons to whom they are directed. 1. Legal, General, or Social Justice -- directly and primarily aimed to the **common good**. These terms are taken here as equivalent. 2. Particular Justice -- directed to the private good. (a) Commutative Justice -- duties of an individual toward other individuals; (b) Distributive Justice -- duties of the community toward the individual. - What is Beneficence? - The principle that imposes on the practitioner a duty to seek the good for patients under all circumstances. - What is Non-Maleficence? - The principle that imposes the duty to avoid or refrain from harming the patient. The practitioner who cannot bring about good for the patient is bound by duty to at least avoid harm. - What is the Principle of Ordinary and Extraordinary Means? - A differentiation used to determine what level of care is ordinary and therefore required, and to differentiate this from that level of care that might be considered extraordinary and therefore optional due to high costs, low effectiveness, or other criteria. **[LEGAL CONSIDERATIONS IN THE CARE OF OLDER PERSONS]** - National Policies on Older People - **Republic Act No. 344** entitled **"the Accessibility Law of 1982"** provides for [the 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, among others. - **Republic Act No. 7876** entitled **"An Act Establishing a Senior Citizens Center in all Cities and Municipalities of the Philippines, and Appropriating Funds"** provides for [the establishment of Senior Citizens Center] to cater to older persons' socialization and interaction needs as well as to serve as a venue for the conduct of other meaningful activities. - **Republic Act No. 8425** provides for the institutionalization and enhancement of the social reform agenda creating the **"National Anti-Poverty Commission (NAPC)"**, which provides a mechanism for older persons [to participate in policy] [formulation and decision-making on matters concerning] [poverty alleviation]. - **Republic Act No. 10155** entitled **"The General Appropriation Act of 2012", under section 28** mandates that all government agencies and instrumentalities should [allocate one percent of their total agency budget] to programs and projects for older persons and persons with disabilities. - **Republic Act No. 9994** entitled **"Expanded Seniors Citizen Act of 2010"** grants [additional benefits and privileges] [to senior citizens], further amending **Republic Act No. 7432** and otherwise known as "an act [to maximize the contribution of] [senior citizens to nation building, grant benefits and special] [privileges and for other purposes]". - 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]"**.** - **Presidential Proclamation No. 1048, series of 1999,** declaring a "[Nationwide Observance in the Philippines of the] [International Year of Older Persons]". - **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. - The Philippine Plan of Action for Senior Citizens (2011-2016) - Aims to ensure giving priority to community-based approaches which are gender-responsive, with [effective] [leadership and meaningful participation of senior citizens in] [decision-making processes], both in the context of family and community. - Aims to ensure active aging for senior citizens where [preventive and promotive aspects of health] are emphasized in communities and where health services are accessible, affordable, and available at all times. - Envisioning a population of senior citizens who are [self-] [sufficient and self-reliant], this plan aims to promote financial security and financial independence of senior citizens by developing community-based local delivery systems to address their needs. - Health and Care - The DSWD has issued **Administrative Order No. 4, series of 2010, "Guidelines on the Home Care Support Services for Senior Citizens",** establishing community-based health care services for older persons. - The **Republic Act 9994** provides health care services for poor older persons such as [free medical services] on government hospitals, discounted services on private hospitals and clinics, free vaccines, discounted medicines, and [mandatory PhilHealth] [coverage]. - Older People's Association (OPA) - The Philippine Constitution supports the formation of community-based organizations. The DSWD have facilitated the formation of older people's associations in every city and municipality. They are also tasked to provide technical assistance to support and strengthen OPAs. - Social Pension - Under the **Republic Act 9994**, the Philippine Government provides a social pension of **Php 500 per month** to poor older persons aged 77 and over who are not yet receiving any government or private pension. The DSWD is the lead agency tasked with identifying and reviewing social pension beneficiaries. - Privileges for the Senior Citizen 1. The grant of 20% discount from all establishments relative to the utilization of transportation services, hotels and similar lodging establishments, restaurants and recreation centers and purchase of medicine anywhere in the country: Provided, that private establishments may claim the cost as tax credit. 2. A minimum of 20% discount on admission fees charges by theatres, cinema houses and concert halls, circuses, carnivals and other similar places of culture, leisure; and amusement. 3. Exception from the payment of individual income taxes; provided that their annual taxable income does not exceed to the poverty level as determined by the National Economic Development Authority (NEDA) for that year. 4. Exemption from training fees for socio-economic programs undertaken by the Office for Senior Citizens Affairs (OSCA) as part of its work. 5. Free medical and dental services in government establishment anywhere in the country, subject to guidelines to be issued by the DOH, the GSIS. 6. To the extent practicable and feasible, the continuance of the same benefits and privileges given by the GSIS, SSS and PAG-IBIG, as the case may be, as are enjoyed by those in actual service. - Free Health Services for Older Persons (subject to availability of facilities and manpower/technical expertise) 1. Medical and dental services 2. Out-patient consultations 3. Available diagnostics and therapeutic procedures 4. Use of operating rooms, special units, and central supply items 5. Accommodations in the charity ward 6. Professional and counseling services **[PASTORAL CONSIDERATIONS IN THE CARE OF OLDER PERSONS]** - Introduction - [Scientific advances] and the consequent [progress of medicine] have made a decisive contribution in recent decades to prolonging the average duration of human life. - The number of older people is constantly increasing, while - that of the young is constantly decreasing. - Inspired by a conviction that older people still have a lot to say and a lot to give to the life of society, [the Holy See (the] [Church) calls for their dignity and fundamental rights to be] [respected] and hopes that the question may be tackled with a great sense of responsibility by everyone: by individuals, families, associations, governments and international organizations, each according to its own competencies and duties and in conformity with the very important **principle of subsidiarity.** - Guidelines for the Pastoral Care of Older People - The ecclesial/Church community is called to respond to the greater participation which older people would like to have in the Church, by turning to account the "gift" they represent [as witnesses of the tradition of faith] (cf. *Psalms* 44:2; *Exodus* 12:26-27), [teachers of the] [wisdom of life] (cf. *Sirach* 6:34; 8:11-12) and [workers of] [charity]. It must therefore re-examine its apostolate on behalf of older people and open it up to their participation and collaboration. - **Charitable activities.** A large proportion of older people have enough physical, mental and spiritual energies to devote their own time and talents in a generous way to the various activities and programs of the [volunteer services]. - **Apostolate.** Older people can make a major contribution to the preaching of the Gospel [as catechists] [and witnesses to Christian life]. - **Liturgy.** Many older people already contribute effectively to the service of places of worship. If suitably trained, they could, in larger numbers, play the role of [permanent deacons], and fulfil the [ministry of lector and] [altar server]. They could also be used in the [extraordinary ministry of the Eucharist and exercise the] [role of animators of the liturgy]. They could also help [promote forms of eucharistic devotion and other forms] [of devotion, especially to Mary and to the Saints]. - **Ecclesial associations and movements.** The growth of many ecclesial associations and communities which represent a great enrichment for the Church---is also due to a form of participation that integrates the various generations, and manifests the richness and fruitfulness of the different charisms of the Spirit. - **The family.** Older people represent the "historical memory" of the younger generations. They are the bearers of fundamental human values. Where this memory is lacking, people are rootless; they also lack any capacity to project themselves with hope towards a future that transcends the limits of the present. The family---and hence society as a whole---will benefit greatly from a revaluation of the educational role of older people. - **Contemplation and prayer.** Older people should be encouraged to consecrate the years that remain hidden in the mind of God to a new mission illuminated by the Holy Spirit. Saint John Paul II, addressing the participants at the International Forum on Ageing, said: "Older people, with the wisdom and experience which are the fruit of a life-time, have entered upon a time of extraordinary grace which opens to them [new] [opportunities for prayer and union with God]. Called to serve others and to offer their lives to the Lord and Giver of Life, new spiritual powers are given to them". - **Trials, illnesses and suffering.** It is important that older people---and not only they---be helped to accept these crosses in a spirit of humble submission to the will of God, in imitation of the Lord. But this will only be possible in proportion as they feel loved and esteemed. Devotion to the weak, to the suffering, to the disabled is a duty of the Church and is proof of her maternal care. [A whole series of services and forms of] [pastoral care should therefore be provided to ensure] [that older people do not feel useless and a burden, and] [to help them to accept their suffering as a means of] [encountering the mystery of God and of man]. - **Commitment to a "culture of life".** Illness and suffering are privileged means for reminding us of the inalienable principle of the sacredness and inviolability of life. Man cannot arbitrarily choose to live or die, or decide on the life or death of others: that is a choice which only he in whom "we live, and move and exist" (*Acts* 17:28; cf. *Deuteronomy* 32:39) can make. Death, regarded as "absurd" if it curtails a life still full of promising and exciting potential, is regarded as a "liberation", to be claimed as a right, if it terminates a life seen as meaningless because overwhelmed by suffering. It is this attitude that forms the cultural context of *euthanasia*, which the Church condemns as "a grave violation of the law of God, since it is the deliberate and morally unacceptable killing of a human person". - The Roman Catholic Church's Pastoral Care Ministry - **Consciousness-raising.** The Church should heighten *awareness of the needs of older people*, not least that of being able to contribute to the life of the community by performing activities appropriate to their condition. This awareness will permit the formulation of qualified forms of intervention. It will also sensitize and involve both the ecclesial and civil communities; and focus attention on those options that are revealed as evangelically and culturally more valid, also with a view to a renewal of the Church\'s charitable works and forms of assistance. - **Countering attitudes of withdrawal.** Older people must be helped to overcome the *indifference* and *mistrust* that hamper their active participation and solidarity. - **Promoting integration.** Older people must be integrated, without any form of discrimination, into the Christian community. All the baptized, in every moment of life, must be able to *renew the richness of grace of their own Baptism* and fully experience it in their lives. No one should be deprived of the grace of God, the preaching of the Word, the consolation of prayer or the witness of charity. - **Developing the service of older people in the community**. The life of the Christian community must be organized in such a way as to encourage the participation of older persons and to *foster the capacities* of each. To this end, [the dioceses should set up their own] [diocesan offices for the ministry to older people; and parishes should] [be encouraged to develop spiritual, community and recreational] [activities for this age group]. The service of older people should also be promoted within diocesan and parish councils and within councils for economic affairs. - **Participation in the sacramental life of the Church.** Older people must be helped to participate in the celebration of the *Eucharist*, in the Sacrament of *Reconciliation* and in *pilgrimages, retreats and spiritual exercises*. Steps should also be taken to ensure that their involvement in such events be not hindered by physical or architectural barriers, or by the lack of specialized personnel to accompany and assist them. - **Spiritual care.** The care and assistance of older people who are infirm or disabled, or no longer in full possession of their physical or mental faculties, should also involve spiritual care; through prayer and communion in the faith, it should testify to the inalienable value of life, even when it is reduced to a terminal condition. - **Sacrament of the sick and dying.** The administration of the *Sacrament of the Anointing of the Sick* and of *Viaticum* must be fostered in a special way, and preceded by appropriate catechesis. Where circumstances permit, it is desirable that priests incorporate the Sacrament of Anointing the Sick in community celebrations both in the parishes and in the places of residence in which older people live. - **Comforting the terminally ill.** Efforts should be made to resist the tendency to abandon the dying and leave them without *religious assistance and human comfort*. This task is not only incumbent on chaplains, whose role is fundamental, but also on the families and communities to which older people belong. - **Caring for those of other faiths.** Particular attention should be devoted, in a spirit of charity and dialogue, to the *older persons of other religious confessions* in order to help them live their faith; nor should Christians be shy of witnessing to their own faith, in a spirit of brotherhood and solidarity, to *older people who are non-believers*. - **A rightful place in society and in the family.** Older people have a right to a place in society and even more so to *an honored place within the family*. The family is called to be a communion of persons. It needs to be reminded of its special mission to foster, manifest and communicate love, and its duty to provide assistance to its weaker members, not least the older persons, and surround them with affection. The need for the family to be able to benefit from adequate means of material support should also be emphasized: economic assistance, welfare and health services, and appropriate housing, pension and social security policies should be available to the needs of the family. - **Caring for older people living in public or private residential structures.** The uprooting of older people from their natural families would be less traumatic if the community were to maintain links with them. The parish community, "family of families", must turn itself into a "diaconia" at the service of older people and their problems. It must also seek to co-operate with the authorities responsible for running such residential homes with a view to finding appropriate ways to ensure the involvement of the volunteer services, the provision of cultural activities and religious service. The latter must ensure that older people are able to be nourished by the Eucharist, and that Holy Communion assumes its significance as participation in the celebration of the Lord\'s Day. The Eucharist must be made present to older people as a sign of the fatherhood of God and of the fruitfulness of life and suffering which risk sinking into grief and even despair, if they are not illuminated by the comfort of the Lord. - **Caring for older adult priests.** It should never be forgotten that the ranks of older people also include *priests*, ministers of the Church and pastors of Christian communities. The diocesan Church must assume responsibility for looking after these older adult priests, and provide them with adequate residential structures and other forms of support. Parish communities too are called to make their contribution; they should take steps to ensure that older priests who retire from their active ministry as a result of old age or poor health find appropriate accommodation. The same goes for religious communities and their superiors, who should devote particular care to their older brothers and sisters. - **Intergenerational solidarity.** The young members of groups, associations and movements present in the parishes must be educated to show solidarity towards the elder members of the community. Such *intergenerational solidarity* is also expressed in the companionship that the young are able to offer to the old. Young people who have opportunities for involvement with older people will appreciate the value of a formative experience by which they gain in maturity and are helped to develop an awareness of others that remains with them for the whole of their life. In a society in which selfishness, materialism, consumerism are rife and in which the means of communication serve little to alleviate the growing loneliness of man, such values as selflessness, dedication, friendship, acceptance and respect represent a challenge to those, not least the young, who are striving for the birth of a new humanity. - Dates to Remember: - **Philippines (1987):** "Grandparents' Day" (every second Sunday of September) - **United Nations (December 14, 1990):** "International Day of Older Persons" (October 1) - **Fidel V. Ramos (PP 470, September 26, 1994):** Linggo ng Katandaang Filipino or Elderly Filipino Week - **Pope Francis (2021):** "World Day of Grandparents and Older Persons" (every fourth Sunday of July) - References: 1. Belmonte, C. (2006). Fundamental Moral Theology. In Belmonte, C. (ed.), *Faith Seeking Understanding* Vol. II. Summa Theologiæ Foundation, Inc. 2. Edge, R., & Groves J.R. (2019). *Ethics of Health Care: A Guide for Clinical Practice* (4^th^ ed.). Cengage*.* 3. Meiner, S. & Yeager, J. (2019). *Gerontologic Nursing* (6^th^ ed.). Elsevier PTE LTD. 4. Pontifical Council for the Laity. (1999). *The Dignity of Older People and their Mission in the Church and in the World.* https:/[/www.vatica](http://www.vatican.va/roman_curia/pontifical_councils/laity/)n[.va/roman\_curia/pontifical\_councils/laity/](http://www.vatican.va/roman_curia/pontifical_councils/laity/) documents/rc\_pc\_laity\_doc\_05021999\_older-people\_en.html. 5. Udan, J. (2020). *Theoretical Foundation in Nursing* (2^nd^ ed.). APD Educational Publishing House.