Unit 8: Ethics and Legal Considerations in the Care of Older Adults (Philippines PDF)

Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 UNIT 8: ETHICO – LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT Introd...

Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 UNIT 8: ETHICO – LEGAL CONSIDERATIONS IN THE CARE OF OLDER ADULT Introduction Senior citizens or elderly refers to anyone who is sixty (60) years old or above. I can say that senior citizens are lucky enough to have reached that age, which means they are now enjoying the fruits of their younger years’ labor. Here in the Philippines, some laws amended and benefits that senior citizens should enjoy; it also applies to dual citizens’ status as long as they can prove their Filipino citizenship and have six months or more stay in the county. Senior citizens become happy and respected as they receive worthiness as citizens of the country with dignity and pride from their household and neighborhood. As we go along this module, we will tackle some of the issues specially made for them. This particular module divided into four (4) lessons: Lesson 8.1 Laws affecting Senior Citizens/Older Persons Lesson 8.2 Medications of Older Adults Lesson 8.3 Ethical Principles Lesson 8.4 Long Term Care and Others Objectives: At the end of this course, the student will be able to: 1. Understand how goals of care influence the appropriateness of medication choice. 2. Recognize key ethical constructs as they relate to the care of geriatric patients. 3. Translate concepts of ethics to their implications in the care of geriatric patients. 4. Relate the influence of personal values, attitudes, and expectations about aging on older adults’ care and their families and extended families. 5. Discuss laws governing gerontological nursing practice. 6. Describe legal issues in gerontological nursing practice and ways to minimize risks. 7. Explain the List of legal safeguards for nurses. Lesson 8.1: Laws Affecting Senior Citizens/Older Persons Lesson Proper Definition of terms Elder law is a specialized legal practice area, covering estate planning, wills, trusts, arrangements for care, social security and retirement benefits, protection against elder abuse (physical, emotional, and financial), and older people. As the population's longevity moves upward, it has become an increasingly popular field. Baby boomers were born in the years following World War II when there was a temporary marked increase in the birth rate. A senior citizen is an older adult, especially one who is retired and living on a pension. A durable power of attorney – a formal, legally endorsed document that identifies a proxy decision- maker who can make decisions if the signer becomes incapacitated. Elder abuse – the physical, emotional, or financial harm to an older person by one or more of the individual’s children, caregivers, or others; includes neglect. COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Elder maltreatment refers to the seven types of abuse and neglect are physical abuse, sexual abuse, emotional or psychological abuse, financial or material exploitation, abandonment, neglect, and self-neglect. Polypharmacy is the use of multiple medications. Instrumental daily living (IADLs) arecomplex skills needed for independent living, such as shopping, cooking, managing finances, traveling by cars, or public transportation. Consent granting of permission to have action has taken or procedure performed A durable power of attorney allows competent individuals to appoint someone to make decisions on their behalf if they become incompetent Duty a relationship between individuals in which one is responsible or has contracted to provide service for another HIPAA Health Insurance Portability and Accountability Act of 1996, assure confidentiality of health information and consumers’ access to their health records Injury physical or mental harm to another or violation of a person’s rights resulting from a negligent act Malpractice deviation from the standard of care Negligence failure to conform to the middle of care Private law governs relationships between individuals and organizations Public law regulates relationships between private parties and the government Standard of care the norm for what a reasonable individual in a similar circumstance would do LAWS GOVERNING GERONTOLOGICAL NURSING PRACTICE 1. Public law governs relationships between private parties and the government and includes criminal law and organizations’ regulation and individuals engaged in certain practices. The scope of nursing practice and the requirements for being licensed as a home health agency falls under public law enforcement. 2. Private law governs relationships among individuals or between individuals and organizations involve contracts and torts (i.e., wrongful acts against another party, including assault, battery, false imprisonment, and invasion of privacy). These laws protect individual rights and also set standards of conduct, which, if violated, can result in liability of the wrongdoer. LEGAL RISKS IN GERONTOLOGICAL NURSING Some nurses do not intentionally commit wrongful acts; however, certain situations can increase their risk of liability. A. Working without sufficient resources, b. not checking agency policy or procedure c and bending a rule, giving someone a break, taking shortcuts d, and trying to work when physically or emotionally exhausted. Acts That Could Result in Legal Liability for Nurses A. ASSAULT A deliberate threat or attempt to harm another person that the person believes carried through COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 (e.g., telling a patient that he will be locked in a room without food for the entire day if he does not stop being disruptive). B. BATTERY Touching of another person in a socially impermissible manner or carrying through an assault. (e.g., performing a procedure without consent). C. DEFAMATION OF CHARACTER An oral or written communication to a third party that damages a person’s reputation. Libel is the written form of defamation; slander is the spoken form. With slander, actual damage must be proven, except when: Accusing someone of a crime Accusing someone of having a loathsome disease D. FALSE IMPRISONMENT The illegal restraint or detention of a person is called false imprisonment. Preventing a patient from leaving a facility is an example of false imprisonment unless shown that the patient has a contagious disease or could harm themselves. Actual physical restraint need not be used for false imprisonment to occur: telling a patient that they will be tied to the bed if they try to leave can be considered false imprisonment. E. FRAUD Willful and intentional misrepresentation could harm or cause a loss to a person or property (e.g., selling a patient a ring with the claim that memory will be improved when worn). F. INVASION OF PRIVACY They are invading the right of an individual to personal privacy. It can include unwanted publicity, releasing a medical record to unauthorized persons, giving patient information to an improper source, or having one’s private affairs public. (The only exceptions are reporting communicable diseases, gunshot wounds, and abuse.) Allowing a visiting student to look at a patient’s pressure ulcers without permission can invade privacy. G. LARCENY The illegal taking of another person’s possession is called theft. (e.g., assuming that a patient will not be using their personally owned wheelchair anymore and giving it away to another patient without permission). H. NEGLIGENCE Omission or commission of an act that departs from acceptable and reasonable standards, which can take several forms: Malfeasance: committing an unlawful or improper act (e.g., a nurse performing a surgical procedure) Misfeasance: performing an act improperly (e.g., including the patient in a research project without obtaining consent) Nonfeasance: failure to take proper action (e.g., not notifying the physician of a severe COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 change in the patient’s status) Malpractice: failure to abide by the standards of one’s profession (e.g., not checking that a nasogastric tube is in the stomach before administering a tube feeding) Criminal negligence: disregard to protecting the safety of another person (e.g., allowing a confused patient, known to have a history of starting fires, of having matches in an unsupervised situation) I. Malpractice According to a standard of care, nurses likely to provide patients' services in a careful, competent manner. The standard of care is considered the norm for what a reasonable individual in a similar circumstance would do. When performance deviates from the middle of care, nurses can be liable for malpractice. Examples of situations that could lead to malpractice include the following: 1. Administering the incorrect dosage of a medication to a patient, thereby causing the patient to experience an adverse reaction 2. Identifying respiratory distress in a patient but not informing thephysician promptly 3. Leaving an irrigating solution at the bedside of a confused patient, who then drinks that solution 4. They forgot to turn an immobile patient during the entire shift, resulting in the patient developing a pressure ulcer e. Having a patient fall because one staff member attempted to lift the patient manually when using a lifting device was the standard f. The fact that a negligent act occurred in itself does not warrant recovery of damages; instead, it has to prove that the following conditions were present: Duty: a nurse has assumed responsibility for the care of the patient Negligence: failure to conform to the standard of care (i.e., malpractice) Injury: physical or mental harm to the patient or violation of the patient’s rights resulting from the negligent act Take note of these: ✓ Duty, negligence, and injury must be present for malpractice to exist. ✓ Caring of the older adults needs others' help, so nurses need to delegate some tasks, and the many competing demands on the nurse contribute to the risk of malpractice. As the task or responsibilities of nurses increases, the risk for malpractice increases too. How will you reduce the risk? ✓ Be familiar with and follow the nurse practice act that governs nursing practice; this is under the specific state ✓ Keep current of and adhere to policies and procedures of the employing agency. ✓ Ensure that policies and procedures follow. ✓ Do not discuss a patient’s condition, share patient information, or access a patient’s medical record to anyone unless the patient has provided written consent. ✓ Consult with the physician when the order is unclear or inappropriate. ✓ Know patients’ normal status and promptly report changes in position. ✓ Assess patients carefully and develop realistic care plans. ✓ Read patients’ care plans and relevant nursing documentation before giving care. ✓ Identify patients before administering medications or treatments. ✓ Documentobservations about patients’ status, care, and significant occurrences. COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 ✓ Ensure that self and subordinates' documentation is accurate and that documentation reflects the care provided. ✓ Know the credentials and assure the competency of all subordinate staff. ✓ Discuss with supervisory staff assignments that have not to administer due to insufficient staff or supplies. ✓ Do not accept responsibilities beyond your capabilities to perform and do not delegate assignments to others unless you are confident that they can perform the delegated tasks. ✓ Report broken equipment and other safety hazards. ✓ Report or file an incident report when unusual situations occur. ✓ Promptly report all actual or suspected abuse to the appropriate state and local agencies. ✓ Attend continuing education programs and keep current of knowledge and skills about your practice. Situations that nurses be liable for negligence include: Failing to take action (e.g., not reporting a change in the patient’s condition or not notifying the administration of a physician’s incompetent acts) Contributing to patient injury (e.g., not providing appropriate supervision of confused patients or failing to lock the wheelchair during a transfer) Failing to report a hazardous situation (e.g., not letting anyone know that the fire alarm system is inoperable or not informing anyone that a physician is performing procedures under the influence of alcohol) Handling patient’s possessions irresponsibly Failing to follow established policies and procedures Are you familiar with your state’s nurse practice act and the regulations governing the area in which you practice or will practice? Confidentiality To protect patients’ health information security and confidentiality, the federal government developed the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides patients with access to their medical records and control over how their personal health information is used and disclosed. Patients can ask their providers to change incorrect information they have discovered in their record or add the missing data. They also can request that their health information not be shared. Patient Consent Patients are entitled to know the full implications of procedures and make an independent decision as to whether they choose to have them performed. Obtain consent before performing any medical or surgical procedure; performing procedures without permission can be considered battery. Consent must be informed. It is unfair to the patient and legally unsound to obtain the patient’s signature for a procedure without telling the patient what that procedure entails. COMMUNICATION TIP When obtaining consent, nurses should assess if the patient or his/her COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 representative fully understands the procedure, its purpose, alternatives, expected consequences, and risks. Every conscious and mentally competent adult has the right to refuse consent for a course. Patient Competency Mentally incompetent persons are unable to give legal consent. Often in these circumstances, staff will turn to the next of kin to obtain permission for procedures; however, a guardian's appointment to approve the incompetent individual is the court's responsibility. GUARDIANSHIP Court appointment of an individual or organization to have the authority to make decisions for an incompetent person. Guardians can be granted decision-making authority for specific types of issues: Guardian of property (conservatorship): this limited guardianship allows the guardian to take care of financial matters but not make decisions concerning medical treatment. Guardian of person: decisions about the consent or refusal for care and treatments by persons granted this type of guardianship. Plenary guardianship (committees): guardians can make all types of decisions pertaining to person and property under this form. POWER OF ATTORNEY The legal mechanism by which competent individuals appoint parties to make decisions for them; this can take the form of: Limited power of attorney: findings are limited to some issues (e.g., financial affairs), and the attorney's ability becomes invalid if the individual becomes incompetent. A durable power of attorney: provides a mechanism for continuing or initiating power of attorney in the event the individual becomes incompetent. To ensure the protection of patients’ rights, nurses should recommend that patients and their families seek legal counsel for guardianship and power of attorney Staff Supervision Gerontological nurses are responsible for supervising other staff, many of whom may be unlicensed personnel. In these situations, nurses are responsible not only for their actions but also for the team's levels they are supervising. Situations that can create risks for nurses: Permitting unqualified or incompetent persons to deliver care Failing to follow up on delegated tasks Assigning tasks to staff members for which they are not qualified or competent Allowing staff to work under conditions with known risks (e.g., being short-staffed and improperly functioning equipment) COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Medications Nurses are responsible for the safe administration of prescribed medications. Preparing, compounding, dispensing, and retailing drugs fall within the pharmacy practice, not nursing, and, when performed by nurses, can be interpreted as functioning outside their licensed scope of practice. Restraints The Omnibus Budget Reconciliation Act (OBRA) heightened awareness of the severe impact of restraints by imposing strict standards on their long-term care facilities. This increased concern regarding and sensitivity to chemical and physical limitations has had a ripple effect on other practice settings. Anything that physically or mentally restricts a patient’s movement (e.g., protective vests, trays on wheelchairs, safety belts, geriatric chairs, side rails, and medications) can be considered a restraint. Improperly used restraining devices can not only violate regulations concerning their use but also result in litigation for false imprisonment and negligence. At no time should controls be used for the convenience of staff. Alternatives to restraints are applied whenever possible. Measures to help manage behavioral problems and protect the patient include alarmed doors, wristband alarms, bed alarm pads, beds, chairs close to the floor level, and increased staff supervision and contact. When restraints are deemed necessary, a physician’s order for the restrictions obtained, stating the specific conditions for which the limits practiced, the type of restraints, and the duration of use. Telephone Orders In-home health and long-term care settings, nurses often do not have the benefit of an on- site physician. Changes in the patient’s condition and requests for new or altered treatments communicated over the telephone and, in response, physicians may prescribe orders accordingly. Accepting telephone orders predisposes nurses to considerable risks because the order can be heard or miswritten, or the physician can deny that the order has given. It may not be realistic or advantageous to patient care to eliminate telephone orders, but nurses should minimize their risks in every way possible. Try to have the physician immediately fax the written order, if possible. Do not involve third parties in the order (e.g., do not have the order communicated by a secretary or other staff member for the nurse or the physician). Communicate all relevant information to the physician, such as vital signs, general status, and medications administered. Do not offer diagnostic interpretations or a medical diagnosis of the patient’s problem. Write down the order as it has given and immediately read it back to the physician in its entirety. COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Place the order on the physician’s order sheet, indicating a telephone order, the physician who gave it, time, date, and the nurse’s signature. Obtain the physician’s signature within 24 hours. Recorded telephone orders may be a helpful way for nurses to validate what they have heard. Still, they may not offer much protection in the event of a lawsuit unless the physician has informed that the conversation is has recorded or unless special equipment with a 15- second tone sound has used. Do Not Resuscitate Orders The caseloads of many gerontological nurses contain a high prevalence of terminally ill patients. All parties involved that these patients will die; however, unless an order specifically states that the patient not resuscitate, failure to save that person’s life view as negligence. Nurses must ensure that DNR (do not resuscitate) orders are legally sound, remembering several points. First, DNR orders are medical orders and must be written and signed on the physician’s order sheet to be valid. DNR placed on the care plan or a special symbol at the patient’s bedside is not legal without the medical order. Next, unless it is detrimental to the patient’s well-being or the patient is incompetent, obtain consent for the decision not to resuscitate; if the patient is unable to consent, family consent. Advance Directives and Issues Related to Death and Dying A variety of issues surrounding patients’ deaths pose legal concerns for nurses. Some of these issues arise long before death occurs when patients choose to execute an advance directive or a living will. Advance directives express competent adults' desires regarding terminal care, life-sustaining measures, and other dying and death issues. There are two types of advance directives. A durable power of attorney for health care is a document that appoints a person selected by the patient to decide on the patient’s behalf should the patient be unable to make or communicate their findings. A living will describe a patient’s preferences and gives instructions to health care providers if, at a future time, he or she is unable to make or communicate decisions and has no one appointed as a proxy. Following an advance directive protects health care professionals from civil and criminal liability when followed in good faith. Nurses advise checking the status of advance directive legislation in their states. Elder Abuse Elder abuse can occur in patients’ homes or health care facilities by loved ones, caregivers, or strangers. Particularly in long-term caregiving relationships, where family members or staff “burn out,” abuse may be an unfortunate consequence. Caregiver stress can lead to the abuse of older adults. There are several recognized types of elder abuse (National Center for Elder Abuse, 2012), which include the following: COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Physical abuse Emotional abuse Sexual abuse Exploitation Neglect Abandonment Abuse may be undetected due to an older person’s lack of contact with others (e.g., being homebound and not having communication with anyone but the relative who is the abuser) or the reluctance to report the problem due to fear or shame. Nurses can assess for abuse using a tool such as the Elder Mistreatment Assessment (Fulmer, 2012). Gerontological nurses must also be alert to indications of possible abuse or neglect during routine interactions with older adults; signs could include the following: Delay in seeking necessary medical care Malnutrition Dehydration Unexplained bruises Poor hygiene and grooming Urine odor, urine-stained clothing/linens Excoriation or abrasions of genitalia Inappropriate administration of medications Repeated infections, injuries, or preventable complications from existing diseases Evasiveness in describing condition, symptoms, problems, and home life Unsafe living environment Social isolation Anxiety, suspiciousness, and depression LEGAL SAFEGUARDS FOR NURSES Common sense can be the best ally of sound nursing practice. Never forget that patients, visitors, and employees do not forfeit their legal rights or responsibilities within the health care environment. Laws and regulations impose additional rights and obligations on patient-provider and employee-employer relationships. Nurses can and should protect themselves in the following ways: Familiarize themselves with the laws and rules governing their specific care agency/facility, their state nurse practice act, and labor relations. Become knowledgeable about their agency’s policies and procedures and adhere to them strictly. Function within the scope of nursing practice. Determine for themselves the competency of employees for whom they are responsible. Check the work of employees under their supervision. Obtain administrative or legal guidance when in doubt about the legal ramifications of a situation. Report and document any unusual occurrence. Refuse to work under circumstances that create a risk to safe patient care. Carry liability insurance COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Here in the Philippines As defined under Republic Act No. 7432, as amended by RA No. 9257(“Expanded Senior Citizens Act of 2003”), and further amended by RA 9994, known as the “Expanded Senior Citizens Act of 2010,” defines senior citizen or elderly as any resident citizen of the Philippines at least 60 years old. List of Senior Citizen Benefits Income tax exemption for minimum wage earners. Training fee exemption on socio-economic programs. Free medical and dental services government facilities. Free flu and pneumococcal vaccinations for indigent senior citizens Senior citizens are entitled to a 20% discount and exemption from the value-added tax (VAT) on certain goods and services for their exclusive use. Among these are purchasing medicines and essential medical supplies, accessories, and equipment; professional fees of attending physicians and licensed health workers, medical and dental services, diagnostic and laboratory fees in private hospitals, medical facilities, outpatient clinics, and home health care services. They are also entitled to a 20% discount on land (jeepneys, buses, taxis, shuttle services, MRT, LRT, PNR), sea shipping vessel, and domestic transport services. Many elderlies do not know that the 20% discount also applies to taxis. This also applies to restaurants, hotels and similar lodging establishments, and recreation centers. Seniors should be reminded, though, that the discount only applies to them. Also subject to the 20% discount are admission fees charged by theaters, cinema houses and concert halls, circuses, leisure, and amusement. In some local government units like Baguio City, SM Cinema Baguio offers free movies to senior citizens who are residents of the city once a day from Monday to Friday. When they die, there is a discount for their funeral and burial services. The law also provides a grant of a minimum of 5% discount on water and electric bills registered in the name of the senior citizen residing therein, and provided that the monthly consumption does not exceed 100-kilowatt hours of electricity and 30 cubic meters of water: Seniors can also get a 5% discount without VAT exemption on particularly on groceries granted by the Department of Trade and Industry and the Department of Agriculture. For groceries worth up to PHP 1,300 per week, they can enjoy 5% off the retail prices of at least four kinds of the following necessities and prime commodities: Rice, bread, and corn; Chicken, beef, and pork;Fresh eggs; Coffee, creamer, and sugar; Fresh fruits and vegetables; Garlic and onions; cooking oil and salt; Noodles, canned sardines, and canned tuna; Fresh milk and other dairy products; detergents; Electrical supplies, light bulbs, and batteries and geriatric diapers. As the government cares for senior citizens' health, they have mandatory Philhealth coverage as stipulated in RA 9994. When they are confined in private hospitals, they can avail of Philhealth benefits and the 20% discount and VAT exemption. In government hospitals, the No Balance Billing Policy applies. COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 To augment their daily subsistence and other medical needs, the government also provides monthly social pension amounting to P500 to needy senior citizens Another privilege of senior citizens is providing express lanes for them in all commercial and government establishments. For the 60 and above citizens to enjoy these benefits and privileges, they must present their senior citizen ID issued by the Office of the Senior Citizen Affairs (OSCA). They may give their government-issued ID that shows their age in the absence of senior citizen ID, but not all establishments honor this. That is why it is essential to apply for their senior citizen's ID at the OSCA or the Department of Social Welfare and Development (DSWD) in their respective cities or municipalities. Senior Citizens who are gainfully employed or who remain to have regular income sources shall continue to pay their premium contributions to PhilHealth under the applicable membership categories. Lesson 8.2: Medications of Older Adults Lesson Proper: Medications of older adults Polypharmacy is the use of multiple medications. The baby boomers (1946-1964) are coming! The older population in 2030 projected to be twice as large as in 2000, growing from 35 million to 71.5 million and representing nearly 20 percent of the total U.S. population. The older Asian population is also projected to experience a massive increase from just over 1 million in 2006 to almost 7 million in 2050. Nutrients recommendations for old age: Nutrients Recommended daily intake for 50+ years Calcium (mg) 700 Phosphorus (mg) 550 Magnesium (mg) 270 Sodium (mg) 1600 Potassium (mg) 3500 Chloride (mg) 2500 Iron (mg) 14.8 Nutrients Recommended daily intake for 50+ years Calcium (mg) 700 Phosphorus (mg) 550 Magnesium (mg) 270 Sodium (mg) 1600 Potassium (mg) 3500 Chloride (mg) 2500 Iron (mg) 14.8 Nutrients Recommended daily intake for 50+ years Calcium (mg) 700 Phosphorus (mg) 550 Magnesium (mg) 270 Sodium (mg) 1600 Potassium (mg) 3500 Chloride (mg) 2500 Iron (mg) 14.8 COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Vitamin D It is recommended that everyone over 65 years of age takes a vitamin D supplement (10μg/day). Good dietary providers of vitamin D (e.g. oily fish, margarine, eggs and fortified breakfast cereals) should also be eaten regularly. Calcium intake Adequate intakes of calcium can help to slow age-related bone loss, which can result in osteoporosis and fracture Recommended intake of calcium per day = 700mg in adults over 50 years old. Vitamin C needs several functions in the body, including forming and maintaining healthy tissues for adequate wound healing. Anti-oxidant action, i.e., helps to protect the body from damage caused by toxins. Vitamin C requirements for older people are the same as younger adults, but unfortunately, intakes are often sub-optimal. Folate and vitamin B12 required together for many functions including cell division good nerve function. Requirements for folate, vitamin B 12, and other B vitamins such as thiamin and riboflavin are either the same or slightly less than younger adults; however, maintaining adequate intakes is essential to prevent deficiency. Iron formation of red blood cells Transport of oxygen to tissues. In females over 50 years old, iron requirements are significantly less than younger females as menstruation usually has ended by this age, and they no longer lose iron in menstrual blood. Drugs that alter nutrient intake Central nervous system stimulant Dexamphetamine Methylphenidate Metformin Phenformin Drugs that alter taste: Metronidazole Medicines that can cause nausea Theophylline Antibiotics (e.g., erythromycin, Flagyl ) Anti-inflammatory drugs Digoxin COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Other drugs that can reduce appetite Cardiac glycosides Glucagon Morphine (opiates) Indomethacin Medications that can alter nutrient excretion Furosemide increases the renal loss of potassium, calcium, sodium, magnesium, and thiamin. Drugs that can alter nutrient excretion Gentamicin, Mithramycin, and Actinomycin D increase the excretion of calcium. Corticosteroids may cause sodium retention. Increased magnesium urinary loss is due to medications such as Thiazides and Frusemide, alcohol, Cyclosporine, and Gentamicin. Polypharmacy and Medication Errors Prescription and OTC drugs. Increased numbers of medications carry high risks. Beer’s Criteria for Potentially Inappropriate Medications in Older Adults Screening Tool of Older Persons’ Prescriptions (STOPP) Screening Tool to Alert to Right Treatment (START) Immunizations Influenza (annual for age 65+) Pneumococcal pneumonia (one time for 65+) Tetanus and diphtheria (booster every ten years for all older adults) Herpes zoster (one time for age 60+) Important Screenings Summary Screen older patients according to USPSTF guidelines. Assess the older adult’s medication list and be aware of polypharmacy. Compliance with drug regimens is essential to improving medical diagnosis and outcomes. COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Lesson 8.3: Ethical Principles Lesson Proper Learning Objectives 1. Recognize key ethical constructs as they relate to the care of geriatric patients. 2. Translate concepts of ethics to their implications in the care of geriatric patients. 3. Relate the influence of personal values, attitudes, and expectations about aging on older adults' care and their families and extended families. 4. Analyze the impact of fiscal, sociocultural, and medico-legal factors on decision-making in geriatric patients' care. 5. Formulate strategies for facilitating appropriate levels of autonomy and supporting the right to self-determination decisions in geriatric patients' care. Ethical/Legal Principles and Issues The ethics of care in the geriatric population is complex and challenging. Mindfulness of autonomy, within changing capacity. Conflict and Dilemma Ethical conflict is a choice between two equal possibilities. Moral distress: – When someone wants to do the right thing but is limited by constraints of organization or society Moral uncertainty: – Confusion in situations when a person is uncertain what the ethical problem is or which moral principles or values apply to it Moral Principles Incorporated into the professional code of ethics, organizational value statements, and position statements published by professional groups Beneficence/nonmaleficence Advocacy, confidentiality, fidelity, and honesty Justice and autonomy Informed consent Quality and sanctity of life COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Elements to include in the discussion o The specific condition requiring treatment o The purpose and distinct nature of the procedure or treatment Potential complications or risks associated with the process or treatment Reasonable alternatives with a discussion of their relative risks and benefits Discussion of the option of taking no action The probability of success of the recommended treatment or procedure Patient Rights Patient rights direct actions on ethical issues in the care of geriatric populations. Advance directives and living wills. – Advance directive: actions to be taken if the patient is no longer able to provide informed consent – Living will: direct preferences for end-of-life care issues, providing an “if... then...” plan A durable power of attorney A legal document designating alternative decision-maker in the event the person is incapacitated Competence Mental clarity and appropriateness for decision making based on a mental status exam Required for persons to exercise autonomy and the right to decide Guardianship Legal appointment of a person to make decisions on behalf of a person who has been found by the court to be incapable of making his or her own decisions Assisted suicide Violation of the Code of Ethics for Nurses Oregon: Death with Dignity Act (1997) Ethics in Practice Medical errors – Considerable effort into reducing mistakes and improving patient safety. – Average hospital patient can expect to be subjected to at least one medication error per day. Conflict of interest – Competing loyalties and opportunities. Framework for ethical decision making provides a foundation for discussion when dilemmas arise, smoothing the way for integrity-saving compromise. COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Lesson 8.4: Long Term Care and Others Lesson Proper Long Term Care and Others Identify assistive technology and methods for teaching older adults about their use. Recognize typical applications of assistive technology to enhance older adults’ functioning, independence, and safety. Describe Internet and Web approaches for assistive technology, including learning activities, health information, and healthcare services that can be used in caring for older adults and their families, along with teaching strategies for its access. Discuss new assistive technologies. Key Terms Assistive devices Assistive technologies Augmentative and alternative communication Emergency response system (ERS) Environmental controls Home health care Internet Nursing informatics Smart home World Wide Web Evaluating the Use of Assistive Technology A review of several studies used to identify assistive devices that are being utilized or show nonuse Typical Applications of Assistive Technology Position and mobility Environmental access and control Self-care Sensory impairment Cognitive impairment Social interaction and recreation Computer-based assistive technology The Internet and the World Wide Web The Internet is not just about data; it is an international community of people who share information, interact, and communicate. Nursing informatics. Varied Examples of Web-Based Applications for Older Adults COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 AARP: http://www.aarp.org Adaptive and assistive technology: http://www.rehabtool.com BrainBashers games and puzzles: http://www.brainbashers.com/CataList, the official catalog of LISTSERV lists: http://www.lsoft.com/catalist.html ElderWeb: http://www.elderweb.com Free greeting cards: http://www.123greetings.com/ Healthfinder: http://www.healthfinder.gov Learn the Net: http://www.learnthenet.com/index.php/index.html National Library of Medicine: https://www.nlm.nih.gov/ SeniorNet: http://www.seniornet.org/ New Technologies New technologies are being developed and used to facilitate evidence-based practice, enhance education, and improve older adults’ quality of life: - Robotic assistance - Sensor-based monitoring - Intel’s assistance program Summary Technologies provide many opportunities for older adults to maintain their independence and stay connected to the world, even when functional limitations are present. Nurses should be aware of the latest technology trends, the use of computers among the older adult population, and how assistive devices help promote autonomy for this cohort. Elder Abuse and Mistreatment Learning Objectives Distinguish between elder abuse and self-neglect. Describe several categories of the mistreatment of older adults. Recognize risk factors for elder abuse. Identify the characteristics of perpetrators of mistreatment. Recognize signs that an older adult is being mistreated. Describe evidence-based screening for elder abuse. Discuss strategies to prevent the mistreatment of older adults. Synthesize interventions in various cases of abuse. Key Terms Abandonment Assault Caregiver burden Chemical restraint Direct physical abuse Elder abuse Elder mistreatment COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Emotional neglect Financial or material exploitation Financial or physical abuse Psychological or emotional abuse Psychological or emotional neglect Respite care Self-neglect Sexual abuse Violation of personal rights Background of Elder Abuse Elder abuse is “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older adult.” Elder abuse or mistreatment is an often-underestimated problem. Types of Elder Abuse Psychological or emotional neglect Psychological or emotional abuse Violation of personal rights Financial abuse Physical neglect Self-neglect Direct abuse Risk Factors of Victims Psychiatric illness/psychological problems Poor physical health or frailty Behavior (provocative/aggressive/resists care) Cognitive impairment Older than 75 years Female Ethnicity Low income Trauma or past abuse Personality traits Characteristics of Perpetrators of Elder Abuse Anxiety History of family violence Inability to meet the needs of the older adult Prevention of Abuse or Mistreatment The best prevention is education, so education about elder abuse should be a priority. Laws regarding elder abuse are not standard from state to state, and the magnitude of elder COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 abuse is not fully realized due to few population-based studies. Assessment and Screening Screening for abuse is imperative to prevent further harm and to advocate for patients’ overall well-being. Recognizing the signs and symptoms of elder abuse or mistreatment: – Abrasion Erythema – Contusion Hematoma – Cut Laceration Treatment and Reporting Treatment will vary based on the type of injury. The three Rs in detecting and reporting elderly abuse: _ Recognize – Respond – Report Sometimes healthcare providers do not report abuse because of fear of repercussion, especially if the investigation turns out to be negative. Care Transitions, System Models, and Health Policy in Aging Describe the continuum of care. Identify the criteria for admission to post-acute levels of care. Compare the settings available for older adult living. Describe the evidence-based care transition models used in different settings. Describe models of community-based care management. Explain initiatives to increase and ensure quality in healthcare delivery. Describe the prospective payment system as it applies to other care (e.g., homecare, acute care, inpatient rehabilitation facilities, long-term care hospitals). Compare the U.S. Medicare and Medicaid programs. Describe the influence of third-party players on health care. Compare the aging policies of Japan, Germany, England, and Canada with those of the United States. Discuss the influence of the different stakeholders on health policy formation. Explain the role of the gerontological nurse in policy formation and advocacy. Healthcare Environment The healthcare environment evolves as the needs and characteristics of the population change, and new approaches to care delivery become part of the continuum of care. Continuum of Care Long-Term Care Nursing homes COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Assisted living facilities Adult day services Care Transitions and Care Coordination Care coordination requires the nurse to work with the older adult as a coach and supporter. Transitional Care Models and Programs Transitional care focuses on transitions or movements between facilities for the elderly and chronically ill. Transitional care engages with patients while hospitalized and then intensively follows patients after hospital discharge. The majority of transitional care interventions focus on the transition from acute care hospital to home. Transitional Care Models and Programs Better Outcomes for Older Adults through Safe Transitions (BOOST) Care Transitions Intervention Transitional Care Model Community-Based Care Management Programs Next Step in Care National Transitions of Care Coalition Initiative to Reduce Avoidable Hospitalizations Community-Based Care Transitions Interventions to Reduce Acute Care Transfers After Discharge Care Management of Low-Income Frail Elderly Guided Care Geriatric Resource for Assessment and Care of Elders Programs of All-Inclusive Care for the Elderly (PACE) Risk in Care Transitions Regardless of which transitions model is applied, transitions in care settings considered to be vulnerable exchange points and contribute to the risk of poor health outcomes. This risk is higher in older adults who may have several chronic diseases, cognitive dysfunction, sensory impairment, and functional decline that coexist with acute and chronic illnesses Nursing Responsibility in Transitioning Care Essential information to be included in a transfer: Detailed assessment Treatments Wounds Current medications COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Allergies Level of independence Recent diagnostic testing Primary care practitioner notification upon discharge and admission to the receiving facility Quality in Care Healthcare systems that collaborate, coordinate care, communicate, and anticipate patients’ needs are essential to ensuring quality nursing care that is “safe, effective, patient-centered, timely, efficient, and equitable.” Definitions Elements of quality healthcare o Quality and safety o Technological advances o National Quality Strategy o The Joint Commission o The Commission on Accreditation of Rehabilitation Facilities o National Quality Forum Quality Indicators Agency for Healthcare Research and Quality Healthy People 2020 Funding Health Care Quality and health outcomes in a healthcare system are related to funding, among other variables. Prospective payment system Medicare Medicare is Title XVIII of the Social Security Act, passed in 1965, after years of trying to provide some kind of universal health insurance. o Medicare Part A o Medicare Part B o Medicare Advantage (Part C) o Medicare Part D Medicaid Medicaid is Title XIX of the Social Security Act. It is an assistance program that is jointly financed by the state and federal governments, but is administered by the state; therefore, coverage and eligibility differ from state to state. Federal funding for Medicaid comes from the general revenues; there is no trust fund set up for Medicaid for Medicare. Money Follows the Person The Money Follows the Person (MFP) rebalancing demonstration program helps states COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 rebalance their LTC systems by transitioning eligible Medicaid recipients from LTC institutions back to the community. Healthcare Funding Options Private insurance Preferred provider organizations (PPOs) Health maintenance organizations (HMOs) Point of service plan (POS) Long-term-care insurance Private pay Patient Protection and Affordable Care Act The PPACA intended to provide affordable health care to enhance the quality of life for all Americans. Components of the Patient Protection and Affordable Care Act. Global Models of Health Care Japan: Insurance has provided through National Health Insurance; a variety of employer-based health insurance plans, and Health Insurance for the Elderly. Germany: The first country to establish a national healthcare program. England: The National Health Service (NHS) is a universal system of health care based on clinical need rather than employment status; care is free at the point of care. Canada: The Canadian healthcare system, known as Medicare, provides universal coverage at no cost at the point-of-care access for physician and hospital services. Health Policy Stakeholders o Patients/consumers in policy formation o Nurses and providers o Government o Organizations/nurse organizations Health Policy Development Lobbying and lobbyists Social policy Public policy Healthcare Policy Related to Aging and Mental Health National Coalition on Mental Health and Aging: http://www.ncmha.org/ National Alzheimer’s Project Act: http://aspe.hhs.gov/daltcp/napa/ World Health Organization: http://www.who.int/mental_health/mhgap/en/ COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)  Republic of the Philippines BULACAN STATE UNIVERSITY City of Malolos, Bulacan Tel/Fax: (044) 791-0153 Healthcare Policy and Health Disparities The demographic profile of older Americans provides the foundation for understanding health disparities that exist. The PPACA includes provisions to address several of the healthcare disparities faced by older adults. Advocacy Nurses can advocate for the uninsured, underinsured, and impoverished in a variety of ways. Nurses also can join other nurses to advocate in small groups or larger groups by joining nurse organizations. Summary The nurse must recognize and institute appropriate client- and family-specific interventions to decrease the potential risk factors in transitioning across healthcare settings for older adults and utilize various evidence-based practice care transition models. COLLEGE OF NURSING (CON) NCM 114A – CARE OF THE OLDER PERSONS (Lecture)