A statewide elder mistreatment virtual assessment program: Legal, ethical, and practical issues.

Telecommunication assisted forensic assessments of capacity and mistreatment by geriatricians with expertise in elder abuse and self-neglect are helping to meet the demand for such forensic services for Adult Protective Services (APS) clients in remote and underserved areas of Texas. The use of synchronous audiovisual assisted interviews instead of in-person interviews with clients to provide capacity assessments has become more important with the arrival of the COVID-19 pandemic. There is growing interest in establishing similar programs in other states using geriatrician faculty from medical schools to serve the clients of their state Adult Protective Services agencies. The arrangement between APS and the geriatricians at McGovern Medical School in Houston, Texas is novel. The structure of the arrangement is important for the success of the program. Legal, ethical, and practical considerations are discussed in this article, including approaches to the Health Insurance Portability and Accountability Act, physician liability, state law, and resource limitations. It is hoped that sharing how one such collaboration has addressed these important issues will suggest approaches for the structuring of similar programs.

The canary in the coal mine: Continence care for people with dementia in acute hospital wards as a crisis of dehumanization.

Continence is a key moment of care that can tell us about the wider care of people living with dementia within acute hospital wards. The spotlight is currently on the quality of hospital care of older people across the UK, yet concerns persist about their poor treatment, neglect, abuse, and discrimination within this setting. Thus, within hospitals, the care of people living with dementia is both a welfare issue and a human rights issue. The challenge of continence care for people living with dementia can be seen as the 'canary in the coal mine' for the unravelling of dignity within the acute setting. This paper draws on an ethnographic study within five hospitals in England and Wales, selected to represent a range of hospital types, geographies and socio-economic catchments. Observational fieldwork was carried out over 154 days in acute hospitals known to admit large numbers of people living with dementia. This paper starts to fill the gap between theory and data by providing an in-depth ethnographic analysis examining the ways in which treatment as a person is negotiated, achieved or threatened. We examine how the twin assaults on agency of a diagnosis of dementia and of incontinence threaten personhood. The acute threats to this patient group may then act to magnify perils to treatment as a person. Our findings suggest that personal dignity and the social construction of moral personhood are both threatened and maintained in such a setting. We show how empirical ethnographic data can lend weight to, and add detail to, theoretical accounts of moral personhood and dignity.

Cultural and ethical considerations in late-life polyvictimization.

This article examines the cultural and ethical considerations for professionals working with older adults who experience polyvictimization. Drawing from the Department of Justice training program, Polyvictimization in Later Life (OVC/TTAC, 2017), topics include cultural competencies, ethical standards, personal and professional ethics, and ethical considerations when working in teams. Also described are specific suggestions and recommendations to ensure sensitive and ethical responses when working with cases involving polyvictimization.

Association between elder abuse and poor sleep: A cross-sectional study among rural older Malaysians.

OBJECTIVES: To examine the association between elder abuse and poor sleep using a Malay validated version of Pittsburgh Sleep Quality Index (PSQI). DESIGN: This study was divided into two phases. Phase I tested the construct validity and reliability of the Malay version of PSQI. Phase II was a population-based, cross-sectional study with a multi-stage cluster sampling method. Home-based interviews were conducted by trained personnel using a structured questionnaire, to determine exposure and outcome. SETTING: Kuala Pilah, a district in Negeri Sembilan which is one of the fourteen states in Malaysia. PARTICIPANTS: 1648 community-dwelling older Malaysians. RESULTS: The Malay version of PSQI had significant test re-test reliability with intra-class correlation coefficients of 0.62. Confirmatory factor analyses revealed that one factor PSQI scale with three components (subjective sleep quality, sleep latency, and sleep disturbances) was most suitable. Cronbach's Alpha was 0.60 and composite reliability was 0.63. PSQI scores were highest among neglect (4.11), followed by physical (4.10), psychological (3.96) and financial abuse (3.60). There was a dose-response relationship between clustering of abuse and PSQI scores; 3.41, 3.50 and 3.84 for "no abuse", "1 type of abuse" and "2 types or more". Generalized linear models revealed six variables as significant determinants of sleep quality-abuse, co-morbidities, self-rated health, income, social support and gait speed. Among abuse subtypes, only neglect was significantly associated with poor sleep. CONCLUSION: The Malay PSQI was valid and reliable. Abuse was significantly associated with poor sleep. As sleep is essential for health and is a good predictor for mortality among older adults, management of abuse victims should entail sleep assessment. Interventions or treatment modalities which focus on improving sleep quality among abuse victims should be designed.

Emergency Medical Services Perspectives on Identifying and Reporting Victims of Elder Abuse, Neglect, and Self-Neglect.

BACKGROUND: Emergency Medical Services (EMS) providers, who perform initial assessments of ill and injured patients, often in a patient's home, are uniquely positioned to identify potential victims of elder abuse, neglect, or self-neglect. Despite this, few organized programs exist to ensure that EMS concerns are communicated to or further investigated by other health care providers, social workers, or the authorities. OBJECTIVE: To explore attitudes and self-reported practices of EMS providers surrounding identification and reporting of elder mistreatment. METHODS: Five semi-structured focus groups with 27 EMS providers. RESULTS: Participants reported believing they frequently encountered and were able to identify potential elder mistreatment victims. Many reported infrequently discussing their concerns with other health care providers or social workers and not reporting them to the authorities due to barriers: 1) lack of EMS protocols or training specific to vulnerable elders; 2) challenges in communication with emergency department providers, including social workers, who are often unavailable or not receptive; 3) time limitations; and 4) lack of follow-up when EMS providers do report concerns. Many participants reported interest in adopting protocols to assist in elder protection. Additional strategies included photographically documenting the home environment, additional training, improved direct communication with social workers, a dedicated location on existing forms or new form to document concerns, a reporting hotline, a system to provide feedback to EMS, and community paramedicine. CONCLUSIONS: EMS providers frequently identify potential victims of elder abuse, neglect, and self-neglect, but significant barriers to reporting exist. Strategies to empower EMS providers and improve reporting were identified.

Have the Answers to Common Legal Questions Concerning Nutrition Support Changed Over the Past Decade? 10 Questions for 10 Years.

Clinical nutrition specialists (CNSs) are often confronted with technological, ethical, and legal questions, that is, what can be done technologically, what should be done ethically, and what must be done legally, which conflict at times. The conflict represents a "troubling trichotomy" as discussed in the lead article of this issue of Nutrition in Clinical Practice (NCP). During Clinical Nutrition Week in 2006, a symposium covering these 3 topics was presented, and later that year, an article covering the same topic was published in NCP In this article, we revisit several legal questions/issues that were raised 10 years ago and discuss current answers and approaches. Some of the answers remain unchanged. Other answers have been modified by additional legislation, court decisions, or regulations. In addition, new questions/issues have arisen. Some of the most common questions regarding nutrition support involve the following: liability, informed consent, medical decisional incapacity vs legal competence, advance directive specificity, surrogate decision making, physician orders for life-sustaining treatment and electronic medical orders for life-sustaining treatment, legal definition of death, patient vs family decision making, the noncompliant patient, and elder abuse obligations. In the current healthcare environment, these questions and issues are best addressed via a transdisciplinary team that focuses on function rather than form. The CNS can play a pivotal role in dealing with these challenges by applying the acronym ACT: being Accountable and Communicating with all stakeholders while actively participating as an integral part of the transdisciplinary Team.

Ethical perspectives on self-neglect among older adults.

Self-neglect is a serious and growing problem among older adults. A 2004 survey from Adult Protective Services (APS) showed that adults age 60 or older were named in 85,000 reports of self-neglect from 21 states (Naik, Lai, Kunik, & Dyer, 2008; Teaster, Dugar, Mendiondo, Abner, & Cecil, 2006). Although rehabilitation nurses are obligated to uphold the autonomy of older adults and strengthen their independence, dilemmas result when people's poor health behaviors put them or others at risk for negative consequences. When making decisions about nursing actions related to self-neglecting elderly people, the basic principles of autonomy, beneficence, nonmaleficence, and capacity must be considered. The purpose of this article is to discuss major ethical perspectives related to self-neglect among older adults.

Violation of ethical principles in institutional care for older people.

This study focuses on issues of elder abuse in residential settings. Violation of ethical principles is shown in the results of this quantitative study aimed at defining the extent, nature and causes of such abuse by employees' unethical conduct towards clients in senior homes (i.e. residential nursing homes) in the Moravian-Silesian region of the Czech Republic. The research sample comprised 454 employees and 488 clients from 12 residential homes for older people. The data were collected from interviews with clients, who also received a questionnaire concerning their satisfaction with the institution. Two questionnaires were administered to the employees, one based on a pilot qualitative study and a second to investigate burnout. Outcomes were assessed according to the extent and form of elder abuse, the causes of elder abuse and the violation of basic ethical principles. The responses, in particular those of employees, revealed both psychological and physical abuse of older clients, and thus violation of two basic principles: respect for the person and non-maleficence. The group at risk of elder abuse comprised aggressive and dissatisfied clients, as well as those with mental problems and dementia. The employees most at risk of being abusers were those who had been employed in institutional care for more than five years, had inadequate knowledge about social services and suffered from burnout. The prevention of elder abuse is recommended to be through education focused on ethical principles, increasing employees' satisfaction by promoting a friendly and safe organizational culture, and providing adequate working conditions.

Aspectos bioéticos en el anciano maltratado / Bioethical issues in elderly under abuse

El avance de las ciencias biomédicas y la tecnología han retrasado la muerte natural y han aumentado la esperanza de vida. Esto no siempre es visto como un logro sino como una carga social y es experimentada de modo negativo por la propia persona, la familia y la sociedad en general, pues pueden llegar hasta la violencia en su trato con las personas de la tercera edad. Este trabajo tiene como objetivo evaluar los aspectos bioéticos en la atención del anciano maltratado para garantizar su dignidad y reconocer en ellos una oportunidad para emplear la experiencia adquirida en el transcurso de la vida(AU)

The progress of biomedical science and technology have slowed the natural death and increased life expectancy. This is not always seen as an achievement but as a social burden and is experienced in a negative way by the individual, family and society in general, they can get to the violence in their dealings with elderly people. This study aim, is to assess the bioethical aspects in the elder care to ensure their dignity and recognize in them an opportunity to use the experiences gained in the course of life

Adaptación lingüística y cultural de dos instrumentos para la detección de sospecha de maltrato hacia las personas mayores / Linguistic and cultural adaptation of two tools for the detecting suspected elder abuse

Este trabajo constituye la continuación natural del proyecto llevado a cabo por la Sociedad Española de Geriatría y Gerontología y el Instituto de Mayores y Servicios Sociales y auspiciado por la OMS y la Universidad de Ginebra, denominado «respuesta global al maltrato hacia las personas mayores incluyendo la negligencia: capacitación de los servicios de atención primaria para el abordaje de un problema mundial». Su realización ha sido posible gracias a la financiación del Instituto de Mayores y Servicios Sociales en el marco del Plan Nacional de Investigación Científica, Desarrollo e Innovación Tecnológica 2004–2007. El objetivo general de este proyecto era la validación tanto de un instrumento para la detección de sospecha de maltrato hacia las personas mayores denominado índice de sospecha de maltrato hacia las personas mayores (EASI) como del formulario de evaluación de trabajo social (FETS) cuyo objetivo era la confirmación de casos de sospecha de maltrato. Tras los resultados obtenidos, en este trabajo se presentan los cuestionarios obtenidos como resultado de la adaptación lingüística y cultural del índice de sospecha de maltrato hacia las personas mayores y del formulario de evaluación de trabajo social(AU)

This work is the natural continuation of the project conducted by the Spanish Geriatrics and Gerontology Society (SEGG) and the Institute for the Elderly and Social Services (IMSERSO) and under the auspices of the World Health Organisation and Geneva University, called “Global response to abuse and neglect of the elderly: Building Primary Health Care Services capacity to deal with a worldwide problem”. The carrying out of this work has been made possible due to funding by the Institute for the Elderly and Social Services (IMSERSO) in the framework of the National Plan for Scientific Research, Development and Technological Innovation 2004–2007. The general aim of this project was the validation of the tool for detecting suspected elder abuse, called (Elder Abuse Suspicion Index, EASI) as well as the Social Worker Evaluation Form (FETS) which is used for the confirmation of suspected abuse cases. After obtaining the results, the questionnaires obtained as a result of the linguistic and cultural adaptation of EASI and FETS are presented(AU)

Benefits and challenges of electronic surveillance in nursing home research.

Cognitive impairment and frailty associated with dementia renders residents of long-term care (LTC) facilities particularly vulnerable to physical and emotional harm. Resident-to-resident violence affects not only the target of the aggression, but also the aggressor, as well as the formal and informal caregivers who must intervene. To date, little research has been conducted on resident-to-resident violence despite preliminary but emerging evidence that it is a common (and likely growing) problem in LTC settings. Exploration of this phenomenon presents multiple pragmatic and ethical challenges. This article presents a rationale for implementing newer technological methods to collect data in investigations of resident-to-resident violence associated with dementia. The advantages and disadvantages of electronic surveillance in LTC research and the ethical principles involved are discussed, and an argument is developed for using electronic surveillance in both the shared, as well as private, spaces of the facility.

[Responsibility of health providers in domestic violence reporting]. / Responsabilidade do profissional de saúde sobre a notificação de casos de violência doméstica.

Domestic violence reporting by health providers contributes to the epidemiological assessment of the magnitude of the problem, which allows the development of specific programs and actions. The aim of the study was to assess the level of responsibility of these providers towards reporting violence, especially domestic violence, and potential related legal and ethical implications. The Brazilian legislation and ethics code of Medicine, Dentistry, Nursing and Psychology were studied. Legal sanctions are found in the Criminal Law of Misdemeanor Offenses, the Child and Adolescent Statute, the Elderly Statute and in the law establishing mandatory reporting of violence against women. There are also penalties in all ethics codes reviewed. It is concluded that health providers have the legal duty of reporting known domestic violence cases and they can even be charged with omission.

Long-term nursing care of elderly people: identifying ethically problematic experiences among patients, relatives and nurses in Finland.

The aim of this study was to explore ethically problematic situations in the long-term nursing care of elderly people. It was assumed that greater awareness of ethical problems in caring for elderly people helps to ensure ethically high standards of nursing care. To obtain a broad perspective on the current situation, the data for this study were collected among elderly patients, their relatives and nurses in one long-term care institution in Finland. The patients (n = 10) were interviewed, while the relatives, (n = 17) and nurses (n = 9) wrote an essay. Interpretation of the data was based on qualitative content analysis. Problematic experiences were divided into three categories concerning patients' psychological, physical and social integrity. In the case of psychological integrity, the problems were seen as being related to treatment, self-determination and obtaining information; for physical integrity, they were related to physical abuse and lack of individualized care; and for social integrity, to loneliness and social isolation. This study provided no information on the prevalence of ethical problems. However, it is clear from the results that patient integrity warrants more attention in the nursing care of elderly patients.