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Volume 2, Issue 7 -- September 1999Protecting Against Humankind's Inhumanity
Elder abuse is relatively new to public awareness. However, this does not make it a new phenomenon. Like other aspects of "man's inhumanity to man", elder abuse has existed as long as elders have. There are four main categories of abuse: psychological, physical, material (financial), and neglect. In many cases it is a spouse, child, or caregiver, who is the abuser. In 1995, the Government of Alberta passed the Protection for Persons in Care Act, which was amended in 1997. This was a positive step in recognizing that elder abuse can occur in publicly-funded facilities, that every person, but especially the vulnerable elderly, has a right to be treated with dignity and respect, and that every citizen has a duty to report suspected abuse. However, the Act only covers facilities at the lodge level of care and up. This is problematic because many elderly are not protected. From an ethics perspective, the Act protects the values of dignity and respect, but does so in an unequal manner. Yet there seems to be no good moral reason to justify treating those elders in public facilities differently than those outside such facilities. Practically, this unequal application can cause tension between private caregivers and community health caregivers. As of 1989, four percent of all seniors (65 and over) living in private dwellings (about 98,000 Canadians), had recently experienced some form of mistreatment. The most prevalent form of abuse is material (financial) abuse. Persons who are over 75 years of age, who are dependent on someone else for daily care, who are isolated, and who exhibit behaviors, such as aggression, wandering, and incontinence, that make them difficult to handle, are at high risk for abuse. In order to demonstrate the need for more expansive elder abuse legislation, I present the following fictional case. While the characters in the case are purely fictional, the events described have all been experienced by our home care team - sometimes in even more extreme circumstances.
The Case of Miss DaisyMiss Daisy was a senior living in rural Alberta. She had many of the risk factors for abuse: she was in her nineties and depended on a sibling (of the same vintage) to look after her well being. Over the last few years, she had become fully demented. She fell frequently, and needed to use a walker and then a wheelchair, but these were refused by her sibling, who encouraged her to be "tough" and independent. She wandered and she was severely incontinent. The only close relative these seniors had, resided in another province. As Miss Daisy's ability to manage her own affairs decreased, this relative obtained signing authority on Miss Daisy's account from the bank. During that period of time, local family members and friends finally convinced the younger sibling to accept some assistance with personal care for her; however, the care giving sibling was extremely independent and vociferously indicated that this intrusion on their privacy was not welcome. When Miss Daisy turned 95, three weekly personal care and client laundry sessions from the community care team were accepted. The care plan involved her sibling and a neighbor who lived on their land rent-free in exchange for services, providing the care she needed on alternate days. One evening, a phone call to the home care Home Support Aide (HSA) was made by the neighbor, requesting an immediate bath and change of clothes for Miss Daisy, as the neighbor would not perform this intimate task. However, no further home care support was accepted by the primary caregiver. This led to the family eventually deciding to hire a private caregiver. After a few false starts, the family were delighted to be able to hire a 24 hour caregiver who was able to move in with the seniors and make their home hers, assuming, as family said, the role of a daughter. The cost of private care giving could comfortably be covered by Miss Daisy's own savings, as she had been a professional and received a monthly pension. Her sibling, on the other hand, had no regular source of income except the Old Age Pension. Home care would continue providing coordination, personal care and respite, but it was now understood that the private caregiver would assume housekeeping duties, provide the personal care required, and ensure Miss Daisy's safety as part of her employment. Unfortunately, but as expected, the health of both seniors continued to deteriorate. They were becoming more frail and mentally less alert and aware as time went by. The HSAs, in their monthly reports, expressed concern that the private caregiver was seldom there when they arrived or left. Smoking pans and charred food would be found on the stove or in the oven, as the seniors slept. Then one day, Miss Daisy was found totally naked in her bedroom with the residence door wide open and the care giving sibling sound asleep. More and more often when home care staff arrived, the client would not yet have eaten, be very weak and unresponsive. Up to this time, home care had tried to respect the primary caregiver's wishes to be left alone, and tried to balance Miss Daisy's need for care with the younger sibling's need for independence and control. In one of several conferences with family and caregivers, the private caregiver told the home care coordinator that she felt threatened by home care staff, fearing the loss of her position and her residence. As a team, home care decided to work closely with the caregiver, offering guidance and support wherever possible. While the private caregiver stated that she was willing to learn and provide the care required, and assured family constantly that she was meeting all the seniors' needs, the situation continued to deteriorate. The inattention to Miss Daisy's hygiene, nutrition and medical care were compounded by the fact that necessary equipment which had been provided to decrease the incidence of falls was not being used consistently. In the midst of all this, another crucial issue came to the fore as one day the younger sibling took a trusted HAS aside and showed her cancelled cheques received in the mail indicating that funds were being withdrawn from Miss Daisy's account for jewelry, cattle and equipment, and a credit card payment. However, because this was a "family issue", the sibling refused to pursue this. Instead, the HAS was asked to secure the cancelled cheques so no one else might find and destroy them. The cheques were placed in a secure location in the home care office. The time then came when there was no money left in Miss Daisy's account and the private caregiver had to add money of her own to the account in order to receive her pay. As the year progressed Miss Daisy was seeing her physician and requiring acute care with increasing frequency. One weekend morning, the home care coordinator received a call at home from hospital staff, stating that a relative had accepted a 2-month respite placement in long term care, in order to allow Miss Daisy's severe wounds to heal. Toward the end of that time, Miss Daisy died.
Teachings From Miss DaisyIn this fictional scenario, a woman who was clearly vulnerable to and did experience abuse, was not protected by the PPIC legislation. Modern professional standards have given us the responsibility to make independent ethical decisions; modern society has given the consumer or her/his surrogate the right to refuse treatment and protection. This leaves home care staff with a strong moral and professional obligation to protect clients, but helpless to assure such clients the care, comfort and dignity they are entitled to as human beings when these individuals are outside the public care context. Sadly, there are, and will be, many "Miss Daisy"s. With our rapidly aging population, and the trend to keep individuals in their own homes as long as possible, aligned with the decrease in institutional beds, there is an urgent need for provincial legislation that recognizes the tragic and clearly unethical reality of elder abuse in the community, and addresses this with firm and effective measures.
Health Ethics: The Global Context
Changes to the PHEN Board
John Boksteyn, Chair of the Palliser Health Authority, and Joyce Halliday, Senior Manager with the Peace Health Region, have been appointed to fill the two previously vacant RHA-appointed board positions. We welcome them and look forward to their continued support and contribution. Regretfully, SheilaMalm has resigned from the PHEN Board due to other commitments. We thank her for her dedication and wish her well with her other duties.
Announcements
Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.
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Updated February 9, 2012
In Touch
This month we are very pleased to
have as our guest writer Kathleen Nychka, a Home Care Coordinator
at the Beaverlodge Health Unit since 1983.
PHEN
Staff have been involved with the organization of a special Pre-Conference
to the 1999 Annual Canadian Bioethics Society Conference. This Pre-Conference,
to take place on October 28,1999 at the Westin Hotel in Edmonton, will
feature speakers from the International Association of Bioethics and
will engage the themes of Poverty and Health Ethics, and Culture and
Health Ethics. For further information on, or to register for this Pre-Conference,
the CBS Conference or the PHEN/JDHEC/SJCEC Post-Conference, please call
(780) 436-0983.
We are
pleased toannounce the addition of two new members to the PHEN Board!