Week 8 Reviewer Ethico-legal Considerations in Care of Older Adults 2024-2025 PDF

LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT/MEDICATIONS/ NCMB314 ETHICAL PRINCIPLES WEEK 8 | THIRD YEAR – MIDTERMS | A.Y. 2024-2025 COLLEGE OF NURSING – VALENZUELA CAMPUS DISCUSSED BY: Prof...

LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT/MEDICATIONS/ NCMB314 ETHICAL PRINCIPLES WEEK 8 | THIRD YEAR – MIDTERMS | A.Y. 2024-2025 COLLEGE OF NURSING – VALENZUELA CAMPUS DISCUSSED BY: Prof. Caroline V. San Diego TRANSCRIBED BY: Micaella Rane S. Valeriano, SN No. 7432 and otherwise known as “an act to TERMINOLOGIES maximize the contribution of senior citizens to nation building, grant benefits and special CONFLICT OF INTEREST - a situation in which a person privileges and for other purposes. is in a position to derive personal benefit from actions or Republic Act No. 10155, “ The General Appropriations decisions made in their official capacity. Act of 2012” CONFIDENTIALITY - It means that professionals ○ Under Section 28 mandates that all government shouldn't share personal details about someone with agencies and instrumentalities should allocate others, unless that person has said they can or it's one percent of their total agency budget to absolutely necessary. programs and projects for older persons and DEPRESSION - a mood disorder that causes a persistent persons with disability feeling of sadness and loss of interest and can interfere Republic Act No. 10645, An Act Providing For the with your daily functioning. Mandatory Philhealth Coverage for All Senior Citizens” ETHICS – moral principles that govern a person's behavior ○ Amending for the purpose, Republic act No. 7432, or the conduct of an activity. as amended by Republic Act No. 9994 by CONSENT – granting of permission to have an action removing the qualification that a senior citizen taken or procedure performed has to be indigent before being covered by MALPRACTICE – deviation from standard of care PhilHealth NEGLIGENCE – failure to conform to the standard of care Republic Act No. 10868, “Centenarians Act of 2016” BENEFITS AND PRIVILEGES OF “SENIOR CITIZEN” ○ An Act Honoring and Granting Additional Republic act No. 344 or the Accessibility Law of 1982 Benefits and Privileges to a FILIPINO ○ Provides for the minimum requirements and CENTENARIANS. standards to make buildings, facilities, and ○ All Filipinos who have turned centenarian in the utilities for public use accessible to persons with current fiscal year shall be awarded a plaque of disability, including older persons who are recognition and a cash incentive by their confined to wheelchairs and those who have respective city or municipal governments in difficulty in walking or climbing stairs, among appropriate ceremonies in addition to the others. LETTER of FELICITATION and centenarian gift RA 7432 of P 100,000.00. ○ Known as “an act to maximize the contribution of ○ Aside from DSWD, other agencies involved in the senior citizens to nation building, grant benefits implementation of the law’s provisions are and special privileges and for other purposes”. Department of the Interior and Local Republic Act No. 7876 Government (DILG), Department of Health ○ or “An Act Establishing a senior Citizens Center (DOH), and Commission on Filipinos Overseas in all Cities and Municipalities of the (CFO). Philippines, and Appropriating Funds Presidential Proclamation No. 470, Series of 1994 Therefore” ○ Declares the first week of OCTOBER of every ○ Provides for the establishment of senior Citizens year as “ Elderly Filipino Week.” Centers to cater to older persons’ socialization Presidential Proclamation No. 1048, Series of 1999 and interaction needs as well as to serve as a ○ Declaring a “Nationwide Observance in the venue for the conduct of other meaningful Philippines of the International Year of Older activities. Persons”. Republic Act No. 8425 Executive Order No. 105, series of 2003 ○ Provides for the institutionalization and ○ Approved and directed the implementation of the enhancement of the social reform agenda by program providing for group homes and foster creating the National Anti-Poverty commission homes for neglected, abandoned, abused, (NAPC). detached, and poor older persons and persons ○ Through its multi-dimensional and cross- sectoral with disabilities. approach, NAPC provides a mechanism for older The Philippine Plan of Action for senior Citizens persons to participate in policy formulation and (2011-2016) decision-making on matters concerning poverty ○ This plan aims to ensure giving priority to alleviation. community-based approaches which are Republic Act No. 9994. “Expanded Seniors Citizen Act of gender-responsive, with effective leadership and 2010” meaningful participation of senior citizens in ○ An act granting additional benefits and privileges decision-making processes, both in the context of to senior citizens, further amending Republic Act family and community. NCMB314: CARE OF OLDER CLIENTS LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT / MEDICATIONS/ ETHICAL 1 PRINCIPLES  LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT/MEDICATIONS/ NCMB314 ETHICAL PRINCIPLES WEEK 8 | THIRD YEAR – MIDTERMS | A.Y. 2024-2025 COLLEGE OF NURSING – VALENZUELA CAMPUS DISCUSSED BY: Prof. Caroline V. San Diego TRANSCRIBED BY: Micaella Rane S. Valeriano, SN RA 9257 Presence of comorbidities or other ○ It shall train community-based health workers diagnosed diseases among senior citizens and health personnel to MEDICATION ERROR specialize in the geriatric care and health It may be related to: Prescribing, Dispensing, problems of senior citizens. Administering or Monitoring of drug. PHARMACOLOGY AND OLDER ADULT Root cause: Attributed to human knowledge based Older person are at a greater risk for adverse drug events deficiencies and a lack of sophisticated systems to support than younger persons because of differences in the body's and monitoring drug therapy utilization of drugs. 2 Important Distinctions in Medication Error Language: Persons 65 and older are prescribed the highest proportion ○ Adverse Drug Reaction (ADR) of medication in relation to their percentage. ○ Adverse Drug Event (ADE) More appropriate predictors of medications response Adverse Drug Reaction (ADR) include general state of health, number and types of other ○ Any noxious, unintended, and undesired effects medications taken liver and renal function, presence of of a drug which occurs at doses in human for comorbidities or other diagnosed diseases. prophylaxis, diagnosis or therapy. CHANGES WITH AGING ○ ADR Clues May Include: ○ Decrease in body water (as much as 15%) and an Difficulties in the activities of daily living increase in body fat. Cognitive changes ○ Increased concentration of water-soluble drugs Falls (e.g. Alcohol) Anorexia, nausea ○ More prolonged effects of fat-soluble drugs. Weight changes ○ Decreased hepatic blood flow. Adverse Drug Event (ADE) ○ Changes in pharmacodynamics in the older ○ Any injury that results in medications used, and person may be caused by decreases in the this includes both ADRs and medication errors number of receptors and receptor binding. that lead to an ADR. Inappropriate medications administered to older ○ NOTE:The use of too many wrong types of persons include: medications increases the risks of both of an ADE ○ Prescriptions for long-acting benzodiazepines, and non adherence persantine FACTORS THAT CONTRIBUTE TO INCREASED RISK OF ADE ○ Long-term use of drugs that are to be used for PHARMACOKINETIC CHANGES short-term use only (e.g., histamine blockers, short-acting benzodiazepines, oral antibiotics) What the body does to the drug. ○ Decreased hepatic blood flow results in Drug Absorption increased toxicity = Increased SGPT, Increased ○ Age-related changes in drug absorption do not PT, PTT usually contribute to a significantly altered drug ○ Results in increased toxicity when older persons response and are generally thought to have less take usual doses of "first-pass effect" drugs significant impact on pharmacokinetics. because a smaller portion of these drug Drug Distribution or Protein-binding concentration would be detoxified immediately ○ Drug distribution into the peripheral circulation by the liver. and tissues is altered as a function of age. Decreases in serum albumin level ○ A decrease in plasma albumin levels with age ○ Leads to altered binding capacity may result in decreased binding of drugs that or ○ May cause increased serum levels of the "free" mainly bound to serum albumin. or unbound proportion of protein-bound drugs. ○ A decrease in total body water and intracellular ○ May result in toxic levels of highly bound drugs water volumes may lead to an increased serum because more unbound drug is available to concentration of water-soluble drugs such as produce its effects lithium or alcohol. The kidneys Excrete Most drugs ○ An increase in body fat may increase the ○ Individuals vary in degree of decline of renal distribution of fat-soluble medications such as function benzodiazepine into fatty tissue, resulting in ○ Predictors of Medication Response Include: prolonged half-lives and drug accumulation General state of health ○ Also relies on the bioavailability of the drug. Number and types of other medications Hepatic Metabolism taken ○ Age-related changes in hepatic drug metabolism Liver (sgpt) and renal function are not easily measured. (creatinine) NCMB314: CARE OF OLDER CLIENTS LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT / MEDICATIONS/ ETHICAL 2 PRINCIPLES  LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT/MEDICATIONS/ NCMB314 ETHICAL PRINCIPLES WEEK 8 | THIRD YEAR – MIDTERMS | A.Y. 2024-2025 COLLEGE OF NURSING – VALENZUELA CAMPUS DISCUSSED BY: Prof. Caroline V. San Diego TRANSCRIBED BY: Micaella Rane S. Valeriano, SN ○ Biotransformation occurs in all body tissues but ○ EX: Warfarin and aspirin- increased risk for primarily in the liver, where enzymatic activity bleeding. alters and detoxifies the drug to prepare it for DRUG-DISEASE INTERACTIONS excretion. Certain disease states may be exacerbated by specific Renal Excretion drug therapies, and these drugs may be contraindicated in ○ The most important pharmacokinetic parameter patients with a coexisting underlying disease. that changes with age. Although the change in ○ Ex. Aspirin, NSAIDs and Atrophic gastritis – GI renal function is extremely variable, the majority hemorrhage of older adults have a decline kidney function. POLYPHARMACY This may require a decreased dose or extension of the dosing interval for certain drugs. Certain disease states may be exacerbated by specific ○ Serum creatinine may be used as indirect drug therapies, and these drugs may be contraindicated in estimate of renal function by calculating patients with a coexisting underlying disease. creatinine clearance. ○ Ex. Aspirin, NSAIDs and Atrophic gastritis – GI ○ Creatinine clearance (ml/min) = 140 – Age (in hemorrhage years) x Weight in Kilograms 72 x Serum Prevention of Polypharmacy includes: creatinine (mg/dl) ○ Use of the same pharmacy to fill all prescriptions ○ For women, multiply final result by 0.85 ○ Notification to all prescribing clinicians of drugs ○ Creatinine – Male : 0.7 – 1.7 mg/dl ; female : 0.4 – used, including: 1.4 mg/dl. ○ Prescribed medications ○ Creatinine clearance is an estimate of ○ Herbal remedies Glomerular Filtration (GFR) and decreases with ○ OTC medications age. ○ Dietary supplements ○ Blood Urea Nitrogen (BUN) – 7-23 mg/dl. Used ○ Vitamins as the gross measure of glomerular function and OMNIBUS BUDGET RECONCILIATION ACT (OBRA) 1987 the production and excretion of urea. Legislated the appropriate use of medications in ○ Alkaline Phosphatase – 34-122 u/l ; Indicator of institutionalized older persons liver disease. ○ Use of chemical restraint PHARMACODYNAMIC CHANGES ○ Use of unnecessary drugs What then does the drug do to the body? ○ Antipsychotic drugs should not be used unless Aging may result in different responses for older adults to necessary to treat a specific condition that is the same drug concentrations at the site of action diagnosed and documented in the clinical record. compared with those observed in younger adult. Beers Criteria Changes in Pharmacodynamics in older person may be ○ Commonly used consensus criteria related to caused by: inappropriate medications. ○ Altered number of receptors or affinity ○ Developed in 1997, and adopted in 1999 by the ○ Decreases in receptor binding centers of medicare and medical services for the ○ Altered cellular responses to the drug-receptor regulation of medications in nursing homes interaction Inappropriate medications administered to older ○ Organ pathologic condition persons include: ○ Altered homeostatic mechanisms ○ Prescriptions for long-acting benzodiazepines, persantine, propoxyphene DRUG-FOOD INTERACTIONS ○ Long-term use of drugs that are to be used for The presence or absence of any food that may reduce or short-term use only. (e.g., histamine blockers, increase the bioavailability of a medication, leading to short-acting benzodiazepines, oral antibiotics) unanticipated effects. ○ High doses of drugs prescribed above dosage ○ Ex. Theophylline and caffeine – increased limitations (iron supplements, histamine blockers, potential for toxicity antipsychotic agents) ○ Levodopa and clonidine – decreased COMMONLY USED MEDICATION antiparkinsonian effect Anxiolytics and Hypnotics DRUG-DRUG INTERACTION ○ Anxiety can be a significant problem in older An interaction between one drug and another can result persons and is often associated with depression from altered pharmacokinetics or pharmacodynamics. & dementia. It is largely thought that alterations in hepatic metabolism ○ According to the Beer's list, benzodiazepines with are specifically responsible for drug-drug interaction. long half-lives should be avoided because of the NCMB314: CARE OF OLDER CLIENTS LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT / MEDICATIONS/ ETHICAL 3 PRINCIPLES  LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT/MEDICATIONS/ NCMB314 ETHICAL PRINCIPLES WEEK 8 | THIRD YEAR – MIDTERMS | A.Y. 2024-2025 COLLEGE OF NURSING – VALENZUELA CAMPUS DISCUSSED BY: Prof. Caroline V. San Diego TRANSCRIBED BY: Micaella Rane S. Valeriano, SN likelihood of accumulation of the patient drug Are not to be used more than twice in a and its active metabolite, resulting in increase 7-day period without Further toxicity assessment unless for the purpose of ○ Daily use of both long and short-term acting titrating dosage for optimal response benzodiazepines unless for management of unexpected Should be limited to less than 4 behaviors otherwise unmanageable. continuous months Cardiovascular Medications Should be limited unless an attempt at ○ The main concerns with the use of cardiovascular gradual dose reduction is unsuccessful medications in older adults are an increased risk Dose reductions should be considered of orthostatic hypotension and dehydration, after 4 months especially with volume-depleting agents and Antidepressants vasodilators. ○ All antidepressants are generally equally Antimicrobials effective and typically take effect in 2 to 4 weeks ○ Dosing of antibiotics may need to be altered in ○ Overall, tricyclic antidepressants should be older clients because of reduced renal avoided in the older patient because of their elimination. anticholinergic and sedative side effects profile Nonprescription Agents ○ The newer SSRIs are often considered the first ○ FDAs division of over-the-counter drug choice for antidepressants in older adults evaluation considers three main criteria when because of their lack of TCA side effects reviewing an request to switch a prescription Antipsychotics product to OTC status: ○ Should be prescribed only when valid and clear A record of established safety data for documentation of need exists, since many side the prescription product is necessary effects occur with use of these agents. The drug's expected use should be ○ Appropriate indications for antipsychotic appropriate for OTC treatment prescription include schizophrenia, paranoid The drug should lack undesirable states, and symptoms of psychosis such as properties and not require special hallucinations and delusions. precautions when used without ○ 3 D's that may justify antipsychotic use: physician oversight. Danger to the resident or others NONADHERENCE(NON-COMPLIANCE) Distress for the resident RISK FACTORS Dysfunction of the resident, including ○ Living alone without social support. interference with basic nursing care ○ Visual or auditory impairments. ○ Conditions inappropriate Antipsychotic drug ○ Increasing use of alcohol. use: ○ Socioeconomic factors. Wandering ○ Unpalatable bulk powders or large tablets. Poor self-care NURSING MANAGEMENT FOR IMPROVING CLIENTS Restlessness ADHERENCE Impaired memory Anxiety If knowledge deficits are a problem, provide verbal Depression education, reinforced with written instructions and allow Insomnia time for client’s feedback. Unsociability Encourage a client who “pharmacy shops” to have Indifference to surroundings prescriptions filled at the same pharmacy each time. Fidgeting Provide and assist remembering to take medications. Nervousness Reduce the impact of drug side effects. Uncooperativeness Give adequate intake of fiber and fluid to reduce Agitated behavior when not a danger to constipation. self or others. Diuretics can be scheduled in the morning to reduce ○ Residents who use antipsychotic drugs should interruptions of activities and sleep. receive Use of Isotonic liquids or sugar-free lozenges can help with Gradual dose reductions dry mouth. Drug holidays ROLE OF THE NURSE Behavioral programming unless Being aware of the routes of eliminations of medications clinically contraindicated and the implication of aging on these routes. ○ PRN dose of Neuroleptics NCMB314: CARE OF OLDER CLIENTS LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT / MEDICATIONS/ ETHICAL 4 PRINCIPLES  LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT/MEDICATIONS/ NCMB314 ETHICAL PRINCIPLES WEEK 8 | THIRD YEAR – MIDTERMS | A.Y. 2024-2025 COLLEGE OF NURSING – VALENZUELA CAMPUS DISCUSSED BY: Prof. Caroline V. San Diego TRANSCRIBED BY: Micaella Rane S. Valeriano, SN Being aware of the effects of aging on the typical signs Issues on Confidentiality and symptoms of medication toxicity. Issues on decision-making capacity Maintaining knowledge of the signs of medication toxicity ISSUES ON CONFLICT OF INTEREST in the older adult 1. Actual Conflict of Interest issues - between family Drawing random, peak and trough medication levels members and caregivers represent the elderly or assist correctly them in decision-making. Knowing when to notify the prescriber of abnormal results. ○ Between spouses and the elder’s wishes and ETHICAL PRINCIPLES interest; Omission or commission of an act that departs from ○ Between family members and the elder’s wishes acceptable and reasonable standards, which can take and interest; several forms. ○ Between a guardian, conservator or other ○ Malfeasance: committing an unlawful or lawfully designated agent and the elder’s wishes improper act. and interests ○ Misfeasance: performing an act improperly ○ Between a caregiver’s business interests and the ○ Nonfeasance: failure to take proper action elder’s interests. Well-being and quality of life. ○ Malpractice: failure to abide by the standards of 2. Perceived Conflicts of Interest – which include those one’s profession which are not actual conflicts in the course of care but ○ Criminal negligence: disregard to protection the may later become conflicts when the elder patient’s safety of another person interest diverge from those who provide the care. ETHICS OF CARE Issues on Confidentiality - in caring for an elderly patient, invariably, there is disclosure made by the family and Include compassion, equity, fairness, dignity, relatives regarding information that may otherwise be confidentiality, and mindfulness of a person’s autonomy personal and confidentiality to the patient alone. within the realm of the person’s abilities and mental Issues on Decision - Making Capacity – Many times, the capacity. older patient’s decision-making capacity ( also referred to ADVOCACY – refers to loyalty and a championing of the as “ competence”) may be required for certain decisions. needs and interest of others, to educate and informed the patients about their rights and access benefits entitled for LEGAL RISKS IN GERONTOLOGICAL NURSING them. Malpractice AUTONOMY- is the concept that each person has a right Confidentiality to make independent choices and decisions. Patient consent BENEFICENCE / NONMALEFICENCE- These concepts of Patient competency do good (beneficence) and do no harm (nonmaleficence) Staff supervision are integral to health care. Medications CONFIDENTIALITY – emphasizes respect for human Restraints dignity that is demonstrated in daily work. Telephone orders FIDELITY – refers to keeping promises or being true to Do not resuscitate orders another, being faithful to commitments and Advance directives and issues related to death and dying responsibilities. Elder abuse FIDUCIARY RESPONSIBILITY – refers to using both fiscal reserves and caregiving resources wisely, potentially requiring a cost-benefit analysis to facilitate decision making. JUSTICE – refers to fairness of an act situation QUALITY AND SANCTITY OF LIFE – quality of life is a perception based on personal values and beliefs, sanctity of life referring to the value of life and the right to live. RECIPROCITY – is a feature of integrity concerned with the ability to be true to one’s self while respecting and supporting the values and views of another. VERACITY – means truthfulness and refers to telling the truth, or at the least, not misleading or deceiving patients or their families. ISSUES TO BE CONSIDERED Issues on Conflict of interest NCMB314: CARE OF OLDER CLIENTS LESSON 7: ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT / MEDICATIONS/ ETHICAL 5 PRINCIPLES