1.6 Elder abuse and neglect
Veronique Fraser, RN, MSc., MSc., Academic Fellow in Clinical and Organizational Ethics Centre for Clinical Ethics and the University of Toronto Joint Centre for Bioethics
Michael Szego, PhD, MHSc, Assistant Professor, Department of Family and Community Medicine, University of Toronto Clinical Ethicist, Centre for Clinical Ethics and the University of Toronto Joint Centre for Bioethics
By the end of this case study, the physician will gain a better understanding of:
- The professional duty to respond to cases of elder abuse and/or neglect in a comprehensive and timely manner.
- The importance of determining capacity and assessing risk in cases of elder abuse and/or neglect.
- The substantive and procedural ethics principles that can that help guide decision making in cases of elder abuse and/or neglect.
Mrs. C is an 84-year-old woman who was brought to the emergency department (ED) after her concerned landlord called the paramedics. The paramedics report finding Mrs. C seated in a recliner, unable to get up. Mrs. C is unable to give an account of how long she had been stuck in the chair; the paramedics estimate somewhere between 24-48 hours.
Mrs. C. is a widow who shares her apartment with her only child, Donald. Donald acts as Mrs. C�s primary caretaker and was not in the apartment when the paramedics arrived. According to the landlord, Mrs. C�s health has been in steady decline over the past year. Sometimes he hears her yelling at night, and on a few occasions he has found her in the building�s garbage room, eating from a can of discarded food. The landlord is very worried about Donald�s ability to care for Mrs. C; he cites multiple prolonged absences and sometimes seeing Donald �drunk.� The paramedics note that Mrs. C�s apartment is filthy, there is no food in the house, and Mrs. C�s medication bottles are either empty or expired. There are no mobility assist devices in the house.
Upon arrival at the emergency department (ED), Mrs. C is clinically stable though mildly hypotensive and tachycardic, and has a slight fever. She is somnolent but easily rousable and she is disoriented to place and time. She is moderately dehydrated and appears to be malnourished. Her arms and trunk are covered in excoriations, some of which are infected, and she has a stage II pressure ulcer on her buttocks. Her personal hygiene is extremely poor; her legs are covered in dried feces and she smells strongly of urine. Her past medical history includes a remote CVA with hemiparesis and mild aphasia, arthritis, and a history of multiple falls. She is diagnosed with a urinary tract infection and �failure to cope.� The plan is to admit her to the short stay unit of the hospital. Geriatrics and social work are consulted.
After 24 hours of hydration and antibiotics, Mrs. C�s vital signs have improved and she is more alert, though remains disoriented. She frequently repeats the word �home� to the nurses, though does not exhibit any exit seeking behavior. Her son Donald arrives and after visiting briefly with Mrs. C announces he would like to take Mrs. C home, believing she �will be more comfortable there and that is what she wants.� Multiple members of the treating team explain to Donald that Mrs. C requires medical care and that discharging her now would be against her medical best interest. Donald is adamant: he states that he acts as Mrs. C�s power of attorney (POA) for personal care and finances, and that he is taking her home.
- Is this case an example of elder abuse? If so, what are the legal and ethical implications of this?
- Why is assessing capacity important in this case? Who is responsible for assessing Mrs. C�s capacity?
- If Mrs. C is found capable of making her own discharge decisions, to what extent should her desire to return home be balanced against a professional duty to promote her well-being? How might this be negotiated?
- If Mrs. C is found incapable of making discharge decisions, does this change the decision-making process? Does an SDM who is also an alleged abuser continue to have the authority to make treatment decisions on a patient�s behalf? Are healthcare providers required to assess the SDM�s capacity as well?
- Describe the ways in which agesism (both on an institutional and individual level) might play a role in the evolution and resolution of this sort of case?
The World Health Organization (WHO) defines elder abuse and neglect as �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 person.�1 Elder abuse includes physical abuse, emotional/psychological abuse, financial/material abuse, sexual abuse, and neglect.1 Ageism, broadly defined as negative social or individual attitudes towards older adults, may contribute to, or enable abuse and/or neglect. In the healthcare context, ageist attitudes may result in negative assumptions of patient capacity, removal of an older patient�s decision making power, ignoring a capable person�s wishes, or treating an older adult like a child.2 Healthcare providers should reflect on their assumptions about the elderly and ensure that they are not treating older adults in demeaning, discriminatory, or dismissive ways.3
Prevalence rates of elder abuse reported in international studies range from 3.2% to 27.5% depending on the definitions of abuse employed and the survey methods adopted.4 In Canada, it is estimated that 4% of non-institutionalized older adults have suffered some form of abuse/neglect.2 Populations who are especially vulnerable to abuse include the very old, those with limited functional capacity, women and the poor.2 Some of the consequences of elder abuse include physical trauma, loss of dignity and self-respect, and increased hospitalization. Elder abuse and neglect has also been associated with increased mortality in older adults.5,6
Since accounts of �granny battering� were first published in 1975,7 the WHO reports that the medical community has been slow to respond to the issue of elder abuse and neglect.4 Some research indicates that this may be precipitated by an overall lack of awareness and clarity on what constitutes abuse and neglect amongst health care professionals.2 Even when cases of elder abuse and/or neglect are identified, the lack of a legal framework may result in cases being inadequately addressed.1 In Canada, there is no specific crime of �elder abuse� though certain aspects of elder abuse and/or neglect may be classified as criminal acts under the Criminal Code (for instance: failing to provide the necessaries of life, s.215; theft, s.334; physical assault, s.265, amongst others.) Moreover, the legal guidance that does exist (mandatory reporting of elder abuse for example) varies according to provincial/territorial legislation, and is subject to additional considerations including whether the abused older adult is capable or incapable of making decisions, and whether the abuse took place in an institution/retirement home or in the community.3
Recognizing and addressing elder abuse is fundamental to honouring the dignity and universal human rights of older adults8 and is a responsibility of all physicians.
Ethical issues/principles addressed in this case
�Preventing and treating elder abuse means encountering ethical issues at nearly every juncture.� 9
Autonomy: All patients who have decision-making capacity, including older adults, have the right to make free and informed choices about their health care. Capacity can be thought of as a person�s ability to understand the information being given to them and their ability to appreciate the consequences of either acting or not acting on the information. Assessing capacity is extremely important in cases of suspected or confirmed elder abuse and neglect: if capable, informed consent is required for supportive interventions. A patient who has capacity has the freedom to make a decision to remain in an abusive situation, or take risks, that an incapable patient may not. Capacity may also have implications for an older adult�s ability to access support and assistance.
Beneficence and non-maleficence: Physicians have a duty to consider the well-being of their patients and to abstain from causing harm to their patients. Elder abuse cases may be especially concerning when a capable patient chooses to expose themselves to a degree of risk that the treating team is uncomfortable with, or when an SDM maker for an incapable patient makes decisions that do not align with what is perceived to be in the patient�s best interests. When a capable patient chooses to live at risk, there will be a conflict between the ethical principles of autonomy and beneficence. Physicians may struggle with their own values and biases with regards to violence, neglect and the elderly.10 Deliberating about the right course of action in elder abuse cases often involves complicated risk/benefit assessment, especially with respect to discharge planning.
Confidentiality: There is general consensus that properly addressing elder abuse requires inter-professional and multi-sector commitment. Community care agencies, hospitals, police departments, emergency medical services, shelters and advocacy groups, are just a few agencies that may be involved in a single case. Deciding when and how to share confidential personal health information among multiple parties should be made with due consideration of the patient�s right to privacy and confidentiality. There may also be concern about who in the treating-team should be informed of suspected abuse for fear of creating prejudice towards the alleged abuser before the claim is substantiated.2
Justice: Elder abuse disproportionately affects vulnerable groups including women, the socially isolated and dependent, and the poor. In today�s healthcare context, wait-lists for long-term care facilities or retirement homes may be long or prohibitively expensive, and community services may be inadequately resourced to provide for the medical and psycho-social needs of elderly patients. Examining ethical issues surrounding elder abuse from a macro-level perspective may include contemplating how systemic factors, including resource allocation, impact instances of elder abuse and or neglect.
- World Health Organization. (2002) The Toronto Declaration on the Global Prevention of Elder Abuse. Geneva: WHO. Retrieved December 15, 2014 from http://www.who.int/ageing/projects/elder_abuse/alc_toronto_declaration_en.pdf
- Registered Nurses� Association of Ontario. (2014) Preventing and Addressing Abuse and Neglect of Older Adults: Person-Centered, Collaborative, System-Wide Approaches. Retrieved December 15, 2014 from http://rnao.ca/bpg/guidelines/abuse-and-neglect-older-adults
- Canadian Centre for Elder Law. (2011) A Practical Guide to Elder Abuse and Neglect Law in Canada. Vancouver, BC: British Colombia Law Institute. Retrieved December 15, 2014 from http://www.bcli.org/project/practical-guide-elder-abuse-and-neglect-law-canada
- World Health Organization. (2008) Global Response to Elder Abuse and Neglect: Building Primary Healthcare Capacity to Deal with the Problem Worldwide. France, WHO. Retrieved December 15, 2014 from http://www.who.int/ageing/publications/ELDER_DocAugust08.pdf
- Cooper C, Selwood A, Linvingston G. (2008) The Prevalence of Elder Abuse and Neglect: A Systematic Review. Age and Ageing. 27:151-160.
- Gorbien MJ and Eisenstein AR. (2005) Elder Abuse and Neglect: An Overview. Clinics in Geriatric Medicine. 21:279-292.
- Burston GR. (1975) Granny Battering. British Medical Journal. 3(5983):592.
- United Nations. (1991) United Nations Principles for Older Persons. Retrieved December 15, 2014 from http://www.un.org/documents/ga/res/46/a46r091.htm
- Anetzberger GJ, Dayton C, McMonagle P. (1997) A Community Dialogue Series on Ethics and Elder Abuse: Guidelines for Decision Making. Journal of Elder Abuse and Neglect. 9(1): 33-50.
- Loue S. (2001) Elder Abuse and Neglect in Medicine and Law: The Need for Reform. Journal of Legal Medicine. 22(2):159-209.
- Beaulieu M. (2010) In Hand: An Ethical Decision-Making Framework. National Initiative for the Care of the Elderly. Retrieved December 15, 2014 from http://www.nicenet.ca/files/In_Hands.pdf
- Employment and Social Development Canada (ESDC). (2011). Elder Abuse Modules. Retrieved Marchr 12, 2015 from http://www.esdc.gc.ca/eng/seniors/funding/pancanadian/elder_abuse.html
- College of Physicians and Surgeons of Ontario (CPSO). (2006) Consent to Medical Treatment. Available at: http://www.cpso.on.ca/policies-publications/policy/consent-to-medical-treatment
- Beauchamp TL and Childress JF. Principles of Biomedical Ethics. 7th ed. London UK: Oxford University Press, 2013.
- Young J. (2006) Ageism in Services for Transient Ischaemic Attack and Stroke. British Medical Journal. 333(7567): 508�509.
- Stall N. (2012) Time to end Ageism in Medical Education. Canadian Medical Association Journal. 184(6): 728.
- O�Connor D, Hall M.I, Donnelly M. (2009) Assessing Capacity Within a Context of Abuse or Neglect. Journal of Elder Abuse and Neglect. 21(2):156-169.