10
Exploring Ethical Issues Encountered With the Older Adult
MARYANNE M. GIULIANTE
LEARNING OBJECTIVES AND OUTCOMES
Upon completion of this chapter, the reader will be able to:
Discuss why nurses, regardless of the setting, frequently encounter older adults in the current health care system
Describe why there is a current shortage of workers able to care for older adults
Discuss how nurses can effectively advocate for the desires and preferences of older adult patients
Discuss why cognitively impaired patients are at higher risk for encountering ethical dilemmas
Describe how the nurse can advocate for patients who are older or those who have cognitive impairment in situations of medical futility
Apply relevant provisions from the Code of Ethics to ethical issues encountered with the older adult
Identify signs and symptoms of elder abuse
Discuss risk factors that predispose one for elder abuse
Caring for older adults is not a specialty area that nurses frequently choose after graduating from nursing school. More popular specialties include critical care, medical–surgical, or oncology nursing. However, as a practicing RN, you have probably cared for many older adults regardless of your specialty, unless you are a pediatric or obstetrical nurse. In addition, you may have realized that ethical quandaries arise with a greater degree of frequency when working with the older adult population. Their medical, physical, economic, and social issues are often age specific. How medical issues manifest in older adults can differ greatly from the presentation of a younger individual. Ethical situations that arise in this population are often complex, leaving nurses to wonder about their role, and if they should voice their concerns to the rest of the health care team or remain silent. Consider the following Case Scenario.
CASE SCENARIO
Angel works in a medical–surgical unit of a large urban hospital. Although this unit has patients with mixed diagnoses and ages, he often finds himself caring for older adults with cancer. Angel works overnight, and often does not have a great deal of interaction with family members. Today, he has agreed to help out during the day and has found himself in the middle of an emotional family discussion. The topic of discussion was his patient, Mrs. Smith. Angel has taken care of her for several days, and has found her to be cognitively intact. She is 83, and has just been diagnosed with end-stage anaplastic thyroid cancer. Angel remembers that this cancer is one of the deadliest, and often patients with anaplastic thyroid cancer do not live past a few months following the diagnosis. Mrs. Smith is somewhat frail already, and has a history of emphysema, heart failure, osteoporosis, and type II diabetes. With his experience and education, Angel realizes that this diagnosis is terminal. She has recently been told by the oncologist working with her that she is unsuitable for chemotherapy, surgery, and radiation (the three forms of treatment for cancer). Her interprofessional team consisting of an oncologist, geriatrician, oncology nurse, oncology social worker, and palliative care specialist is recommending only palliative (comfort) care. Though saddened, Mrs. Smith seems accepting of this news and verbalizes her agreement to focus on her comfort. However, Mrs. Smith’s daughter, her health care proxy (HCP), is visibly upset and agitated and tries to convince her to go to another hospital for a second opinion. Although Angel thinks that this request is reasonable, Mrs. Smith does not want to go, and is asking for him to convince her daughter that she should stay in this hospital. Mrs. Smith states, “I have had a long life, and I am ready to die.” Angel is uncomfortable with this discussion, and believes that Mrs. Smith’s wishes should be respected.
Question to Consider Before Reading On
1. How would you respond to Mrs. Smith’s family if it asks why a geriatrician is needed on her medical team?
It is imperative that we make a clear distinction that older adults are not the same as middle-aged adults. They have different issues, by virtue of their age, that should cause us to evaluate what makes them unique. Age does become an important factor when we consider certain aspects of care (such as social support, physiologic functioning, and diseases that typically affect this population). However, we need to consider much more than only the chronological age of the patient. Functional, cognitive, and social issues must be taken in consideration to allow us to provide the most holistic care possible. Older adults should not be judged solely by their chronological age, as their age is just one of a variety of factors that informs us about their health status. An unfit 56-year-old is unlikely to have the same issues as a fit 76-year-old. This understanding will be the foundation of how we analyze our patients as it relates to questions surrounding ethics and other aspects of age-appropriate care.
GROWING POPULATION OF OLDER ADULTS
Question to Consider Before Reading On
1. Why are nurses more likely to care for older patients in the current health care environment?
It is important to recognize that there has been tremendous growth among the older population in the past decade. In addition, we should be aware of the data regarding anticipated growth in coming years. Evaluating these statistics can help properly frame this group’s overrepresentation in health care markets, understand their unique needs, and anticipate the ethical quandaries that may arise. According to the U.S. Department of Health and Human Services, Administration for Community Living, the adult population over the age of 65 has increased from 35.9 million in 2003 to 44.7 million in 2013 (a 24.7% increase) and is projected to more than double to 98 million in 2060 (Administration on Aging, 2014). In addition to the growth of this segment of population, the subsegment considered “older-old” is expected to surge. This population of 85+ is projected to increase from 6 million in 2013 to 14.6 million in 2040 (Administration on Aging, 2014; see Figure 10.1).
CAUSES OF MORBIDITY AMONG OLDER ADULTS
These statistics may help us understand the proportion of the population that older adults represent; however, there is still more to know. To appreciate the entire picture, we must evaluate the most common patients that nurses are likely to encounter in their practice. Not only do older adults represent a fair percentage of the population as a whole, but they are frequent utilizers of health care. According to the National Council on Aging, “approximately 92% of older adults have at least one chronic disease, and 77% have two. Four chronic diseases—heart disease, cancer, stroke, and diabetes—cause almost two-thirds of all deaths each year” (NCA, 2016). This data may provide insight into the kind of ethical quandaries that older adults and their caregivers are likely to encounter.
Figure 10.1 Percentage change in the world’s population by age: 2010 to 2050.
Source: United Nations (2013).
Older adults frequently experience multiple chronic conditions (otherwise known as “multimorbidity”), making them potentially more frail and vulnerable. The degree of frailty and chronicity of illness that older adults experience can predispose them to ethical quandaries. According to Journal of the American Geriatrics Society, “Multi-morbidity is associated with higher rates of death, disability, adverse effects, institutionalization, use of healthcare resources, and poorer quality of life” (American Geriatrics Society [AGS], 2012). These data illustrate why nurses caring for older adults may encounter more ethical challenges than those caring for a younger population. Because their care can be more complex, nurses and other providers must understand the needs of the older adult and advocate for them using ethical competence and judgment.
Never before has the cost of health care been scrutinized as much as it is today. With the implementation of the Patient Protection and Affordable Care Act, commonly called the Affordable Care Act (ACA), cost has become a major influencing factor in health care decisions. The quality of care is also constantly evaluated. As a result, the provision of ethically competent care that is appropriate and cost-effective has become more important than ever before. As an example of this paradigm shift, we can return to the chapter Case Scenario and identify relevant issues that may arise in the era of the ACA.
CASE SCENARIO (CONTINUED)
As has already been established, Mrs. Smith is 83, and has recently been diagnosed with a terminal disease. She appears cognitively intact, accepting of the disease and its anticipated trajectory. However, her family seems unwilling to share this acceptance. If we examine this case through the lens of a provider who is conscious of current trends and limitations in health care, it may seem reasonable to forgo curative therapy and focus on keeping Mrs. Smith comfortable (especially given the fact that her medical team does not recommend any anticancer treatment). Interventions such as additional blood tests or scans and providing an anticancer therapy drug may be costly, burdensome, potentially uncomfortable, and likely result in poor clinical outcomes. Mrs. Smith may already be somewhat frail given her age and presence of multiple comorbid medical conditions, which will further undermine the medical team’s ability to achieve a favorable outcome.
Question to Consider Before Reading On
1. How would you respond if Mrs. Smith’s daughter asked, “If my mom is going to die anyway, why not try a little chemo on her. . . . what’s the difference”?
Ageism
What is “ageism”? According to Ageismhurts.org, ageism is, “The stereotyping or discrimination of a person or group of people because of their age” (Ageism Hurts, n.d.). This stereotype suggests that people are treated differently based on their age, and not their functional ability. Generally speaking, employing stereotypes is frowned upon. However, ageism seems to have endured, while other prejudices such as racism and sexism are not socially acceptable. We often crack a smile when comedians joke about somebody with gray hair who drives too slowly. However, these insensitive comments can have long-lasting effects on older adults and those who care for them. We may be quick to react negatively to comments such as these when we become the subject of the jest. Remarks highlighting the noteworthy value of youth in our Western society seem to undermine our inability to appreciate and respect our older adults.
As nurses, we should support a paradigm shift that does not evaluate a person based on their chronological age, but on their functional status. Return to the chapter Case Scenario to explore how ageism could play an unintended role in Mrs. Smith’s care. If she were not a frail 83-year-old with multiple comorbid medical conditions, but a fit 83-year-old who was healthy and jogged 2 miles a day, we may consider her ability to withstand the rigors of anticancer therapy differently. Although the medical team may persist in recommending a focus on palliation, this fit 83-year-old may have a different disease and life trajectory. Functional status and anticipated disease trajectory should be determining factors in the care provided, not merely how long Mrs. Smith has been alive.
To emphasize this point further, let us consider Mrs. Smith to be 53, not 83. At first glance, we might assume that this individual will be healthy and vibrant. However, as we learn about the functional status of this 53-year-old, we are surprised that she is bedbound and frail, resulting from double below-the-knee amputations secondary to uncontrolled diabetes. In addition, she is completely blind. This is not the image that we generally have of a 53-year-old, right? We should apply this insight to older adults as well. There are many 66-year-olds who are frailer, sicker, and less functional than 83-year-old adults. In summary, age is just a number!
Respecting Autonomy and Beneficence
Many older adults struggle with maintaining independence, often their most important goal. Multiple chronic conditions and frailty may affect their functional status. Care providers are sometimes met with resistance from older adults when we advocate for “safety over independence.” This becomes a very difficult situation, especially when family members diminish in number or in their ability to participate in care of the older adult. How can we effectively advocate for the safety and health maintenance of the older adult when their care may exceed the ability of family members and/or their financial resources? These difficult questions become the basis for further discussion, and are rarely easy.
As nurses, we recognize our obligation to advocate for our patients. This role seems easier to enact at certain times than in others. For example, this professional responsibility may feel quite easy when we share a critical aspect of our patient’s care that has been overlooked. Perhaps we think that integration of this key information will support a favorable clinical outcome. We may feel relatively comfortable providing the necessary information to clarify what our patient needs, and see ourselves as our older adult patient’s strongest ally. We may feel satisfied when we witness our patient receiving more comprehensive, patient-centered care because of our efforts (Box 10.1). These successful advocacy experiences reinforce this aspect of nursing care in a positive way, and our patients and their caregivers may be overtly grateful for our efforts. The lines may become somewhat blurred, however, when we are advocating for the health care team’s recommendation and it runs counter to the wishes of our older adult patient. It may be then that we question how to fulfill our responsibilities, without disrespecting our older adult patient. Providers are challenged when they perceive a dichotomy between what is deemed right and what the patient wants. How can we as nurses walk this “tight rope?”
Box 10.1
QSEN Box Example: Patient-Centered Care
Providing patient-centered care to the older adult population is critical. In the case of Mrs. Smith, Angel is mindful of this QSEN competency when he considers the best care that can be rendered to his patient with terminal cancer. He explores ways to deliver care in a safe, comprehensive manner while keeping her wishes at the forefront of his mind. Angel may be somewhat conflicted regarding his ability to successfully navigate this clinical situation. Requesting his colleagues in the medical team to help him tackle this situation is the best way to deliver high-quality, patient-centered care for this older adult patient.
Question to Consider Before Reading On
1. Your older adult patient refuses transfer to a facility to maintain safety following an acute care episode, stating, “I want to go home, even if it means I fall and break a hip, or die!” How would you respond?
CASE SCENARIO (CONTINUED)
Returning to the Case Scenario, let us reflect back to the clinical care of Mrs. Smith. We are going to modify the case a bit to illustrate the points discussed previously. Instead of agreeing with the team of health care providers and advocating for palliation (comfort), let us say instead that Mrs. Smith wanted to take the more aggressive approach, despite professional opinion that does not support anticancer treatment. Let us further imagine that her family was taking a spirited position of encouraging her to choose the less aggressive approach, and they are leaning toward seeing this difficult situation in the same way as her medical team: focusing on palliation. Additionally, let us say that Mrs. Smith reports having heard of an international clinic that reports great success with treating patients with her type of cancer. She reports all related expenses (including travel, hotel accommodations, and treatment costs) would total $1M, and she is willing to spend all of her life savings on this last-ditch effort. She reports being able to physically “make the trip.” You disagree, and believe that she is so severely physically limited that you as her nurse believe that her safety would be at risk by taking such a trip. She may even die in transit.
Question to Consider Before Reading On
1. How can you apply Provision 3 of the Code of Ethics to promote, advocate for, and protect the rights, health, and safety of Mrs. Smith in the Case Scenario?
Box 10.2
Evidence-Based Practice Box: Decision Making in the Absence of Capacity
Determining who will make health care decisions when the patient cannot may be confusing for nurses and other health care professionals. There are two approaches that can be employed in the situation where your patient has lost the capacity to make decisions on his or her own. The first is looking for “advance directives,” such as a “living will,” which will guide health care teams regarding major medical interventions, procedures, and end-of-life care. The second is “surrogate decision making,” such as health care proxy or other surrogate decision maker. This person has the same decision-making authority as the patient himself or herself. A health care surrogate may be any competent adult over the age of 18. Formal surrogates may be specified by state law in a hierarchy, typically in descending order of relation to the patient. Informal decision makers are other family members or close friends who are asked by the health care team to help make decisions on the patient’s behalf. When a patient has not made his or her wishes clear, substituted judgements assess what the patient would have wanted based on prior statements and patterns of decision making.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
