Volume 1, Issue 07 - September 1998

Elder Abuse In The Home

What is Elder Abuse?

Elder abuse can include physical, emotional, sexual, medication and financial abuse and/or neglect of the elderly. Often, more than one of these are involved in an abuse situation. Elder abuse is unique due to factors such as adult dependency, age, health status, stress on caregivers and care recipients and the difficulties of problem identification.

Victims of elder abuse may feel self-blame, low self-esteem, guilt, anger, unhappiness, despair and a multitude of other emotions that negatively impact his/her life.

Elder abuse is a growing problem. By the year 2041, over 23% of the population will be over 65 years old. This is compared with 12% of the population in 1995. This demographic shift is occurring as the 'Baby Boomers' reach retirement age while life expectancy in Canada is increasing.

A Sample Case

Mrs. P, a senior and widower, lives alone and has very few social contacts. Only one of Mrs. P's daughters lives close by. This daughter buys groceries for her mother and pays the bills out of Mrs. P's pension cheque. A home care worker visits daily to assist with some of the activities of daily living.

Over a period of time, the home care worker observes that often there is very little food in the fridge. One day, after noticing an overdue statement from the gas company, the home care worker gently inquires if anything is wrong. Mrs. P breaks down and tells her that her daughter recently lost her job and her son-in-law is addicted to VLTs.

Mrs. P knows her daughter is taking her money. Mrs. P feels guilty and ashamed for not being able to help her daughter and is afraid if she confronts her daughter she will stop helping and visiting.

Why Haven't I Heard About Elder Abuse?

Elder abuse is not a new phenomenon. In this century, cases of 'granny battering' captured the media's attention in the late 1970s. But overall the problem has not received as much attention as other forms of family violence such as spousal and child abuse. In terms of education and awareness, "we are at the point where spousal abuse was 15 years ago," says Jeannette Wright of the Elder Abuse Intervention Team in Edmonton.

Much of the lack of attention to elder abuse stems from the difficulty in defining what it is and how it is a separate entity from other forms of abuse. Lack of research and statistics on elder abuse and an overwhelming reluctance by both seniors and health care providers to report elder abuse have hindered efforts to understand and counter this type of abuse.

Addressing Elder Abuse

A starting point for addressing elder abuse is recognition of the fact that no one deserves to be abused. This stems from the fundamental right of every person to be treated with respect and dignity. Abuse is a violation of this right and is unethical.

Whilst it is clear that abuse is unethical, the context that it is situated in makes the issue more complicated. Elder abuse is perpetrated most frequently by a family member or someone 'known' to the elder. Thus the act of abuse often occurs within the context of an existing relationship which will likely include such 'messy things' as love, hate, anger, forgiveness, memories, codependences and a myriad of other complex factors.

A senior may rely on the abuser for help or company as in the case of Mrs. P. When the abuse is between parent and child, the senior may blame him-/herself for failing in parenting.

That elder abuse occurs within the context of relationships does not condone or excuse the abuse. It merely points to the necessity for a sensitive approach to elder abuse situations. As Constable Steve Matthews, a liaison with the Elder Abuse Intervention Team (Edmonton) states, "You're looking at problems that sometimes go back 50 or 60 years. You're not going to solve that overnight."

Reporting Elder Abuse

The Protection of Persons in Care Act came into force January 5, 1998. It contains a mandatory requirement to report suspected or actual abuse of adults in care, regardless of other laws protecting confidentiality (except for within solicitor-client relationships). Since only approximately 11% of Alberta's seniors are in long-term care facilities, this legislation does not apply to the majority of elder abuse cases.

Autonomy v. Beneficence

Elder abuse cases can create difficult ethical dilemmas for health care providers. For example, health care providers may find that upon talking with a client they suspect/know is being abused, the client may strongly oppose reporting and/or intervention. A provider may then find him-/herself torn between the value of a patient's autonomy and his/her own professional ethic of beneficence (to do good).

The right to self-determination is highly regarded, and legally enshrined in Canada. This value has it that competent persons have the right to decide for themselves what is in their best interests. The majority of seniors are competent. If an individual has questionable capacity to make autonomous decisions the health care provider may conduct/request an assessment of decision-making capacity. However, to always question decision-making capacity when disagreements occur is to make a mockery of the right to self-determination. In fact, not respecting autonomy may further disempower an individual, rendering him/her even more dependent and vulnerable.

It can also be argued that living in fear reduces an individual's freedom to act. Choices are necessarily narrowed in an abusive relationship; who would truly want to be abused, afraid and unhappy? That individuals remain in abusive situations returns again to the complex dynamics of relationships.

Approaching this dilemma from a relational ethics standpoint we might ask: how best can we handle the tension between beneficence and autonomy given the relationships involved? Working from within the context of the abused/abuser relationship, relying on elder abuse resources in the community, may be more beneficial than forcing an artificial separation upon the senior. Empowering an individual through information, education and intervention may increase his/her personal autonomy.

Confidentiality

This leads us to the issue of involving third parties in confidential matters. Some feel that disclosure against a competent person's wishes is inappropriately paternalistic and may lead to a decrease in the self-disclosure of abuse because of a victim's fear of the consequences. Others counter by arguing that the violation of a person's human rights through abuse, warrants the breach of confidentiality.

Most health care providers are aware that 'charging' into a suspected abusive situation can escalate the seriousness of that situation and may jeopardize both the provider's and abused senior's safety. However, in the case of immediate danger to oneself or the senior any individual is justified in contacting the local police service.

In less urgent cases, the health care provider can begin by developing resources and gathering information. This information can then be presented to the abused senior and intervention options proffered. The abused senior may be hostile to information and/or interventions and reject any help. For this reason abuse agencies aim to provide information in the safest, least threatening manner and environment.

However it is handled, disclosure must be carefully considered and must include a commitment to continued support of the abused senior.

Conclusion

Health care providers should aim to empower seniors who are struggling in abusive relationships. They should be aware of what constitutes elder abuse and what the indicator signs are. As the problem of elder abuse is acknowledged, greater information and services are gradually becoming available. These resources can assist health care providers raising and addressing the issue of elder abuse with seniors.

For information on resources available in Alberta, please contact either PHEN office. To report a case of abuse contact the Protection of Persons in Care line at 1-888-357-9339 (business hours).

Announcements

• PHEN is holding a retreat for its Board of Directors and staff on September 28, 1998. The purpose of the retreat is to review the Network's progress to date, set directions for the future and re-evaluate PHEN's organizational structure. To make this process more inclusive and representative, we would like to strongly encourage you to take 10-15 minutes of your time and provide us with your thoughts on the progress of the Network to date and what/how you see it contributing to the Alberta health system in the future. You may do this either by:
  1. completing and returning the enclosed fax response form, or
  2. visiting our web site and filling out an on-line questionnaire. Your comments and thoughts will be very much appreciated.

• The Network has proposed to coordinate a project entitled the Alberta Health Ethics Speaker Series. Sponsored in conjunction with the John Dossetor Health Ethics Centre, St. Joseph's College Ethics Centre, the U of C Office of Medical Bioethics and various health professional associations/regulatory bodies such as the AMA and AARSW, the Series will annually bring a high-profile speaker to Edmonton, Calgary and possibly one additional Alberta venue to address a topical issue in health ethics. If you would like to be involved with this project, either as a representative of your professional/regulatory body or RHA, or as a member of PHEN, please contact a PHEN office near you.

• In the next few weeks, PHEN will be hosting a conference call between representatives from various Health Ethics Networks in North America to share experiences about the successes of, and challenges facing these networks, and to deliberate on what such networks can accomplish. To date, Health Ethics Networks of Manitoba, Southern Ontario, Los Angeles, Florida, Colorado and Vermont have agreed to take part. If you would like more information or know of a Health Ethics Network that may be interested, please call a PHEN office.

• The fall schedule of workshops in health ethics offered by PHEN is beginning to fill up. Workshops already booked include Introduction to Health Ethics, Approaches to Ethical Decision-Making, Ethics Committees, Resource Allocation, End of Life Issues, Informed Consent, and Capacity - to be held in Grand Prairie, Fort McMurray, Peace River, Edmonton, Red Deer, Claresholm and Calgary. We recommend workshops be booked at least 8-10 weeks in advance. More information is available at our web site.

• PHEN is looking for two volunteers to assist with literature searches and retrieval from libraries. The positions require a commitment of three hours per week and are ideal for students looking for experience working in the setting of a health ethics organization. If you know someone who may interested in one of these positions, please ask them to contact PHEN's Edmonton office.

• Associated Medical Services Incorporated is offering various grants to students and researchers in the field of health ethics. Application deadlines for these grants are approaching fast. Please contact either PHEN office for more information.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.