The Ethics of Suspecting Abuse of an Elder

Abstract

Dr. Evans is a full-time long-term care physician in Charlottesville, Va., and medical director of two skilled nursing facilities. He serves on AMDA's board of directors and Caring for the Ages' editorial advisory board.DiscussionIs this a case of elder abuse? What more should the physician or the facility do about it? Must it be reported?When the physician did tell facility staff and management of the suspicious incidents, they insisted that they were unaware of any instance of physical violence and that none of their licensed staff was aware of any shouting or verbal abuse directed toward their resident. All were painfully aware of the resident's long history of verbal abuse directed at them, however. In the overwhelming majority of states, licensed health care workers are required to report suspected abuse, neglect, or exploitation of seniors to appropriate persons—typically, adult protective services or local law enforcement. An employee of a licensed care facility may generally meet this requirement by reporting it to his or her supervisor, who in turn is obligated to report it to the appropriate agency. A suspicion of abuse, neglect, or exploitation is all that is required for a report, not proof of mistreatment.A health care worker is not required to conduct an investigation. A facility may do so and subsequently decide that no mistreatment occurred. Underreporting is widespread. Reporting by physicians is especially uncommon.In this case, it appears that reporting to authorities would be required, despite the patient's own protestations and the likely negative repercussions from the patient and his family. However, it is unlikely that any meaningful intervention would occur as a result.Factors in MistreatmentMistreatment may take the form of physical, emotional, or sexual abuse; physical or emotional neglect; or financial exploitation. Because individuals with physical or cognitive impairment, children, and seniors are considered more vulnerable to mistreatment and less able to report it than others, state laws have imposed reporting requirements on licensed health care workers.Aabout half of all cases of elder mistreatment reported to authorities are substantiated by further investigation. Self-neglect is the most common form of mistreatment reported and substantiated. Physical abuse appears to be far less common than neglect. Meanwhile, financial exploitation of seniors appears to be on the rise.Impairments in cognition and function and resultant dependence on others for care are risk factors for elder abuse. The victims of elder abuse and the perpetrators are usually well known to one another if not living together.In addition, individuals who have a history of abuse directed toward their own family members and those with a history of substance abuse are themselves more likely to become victims of elder abuse later in life, often at the hands of the individuals previously abused by those elders. Consequently, in addition to the “caregiver stress” model of elder abuse, a model not unlike abuse among younger individuals is “family violence” elder abuse. In the case described here, a pattern of abuse was established by the father many years ago, and it appears to have long punctuated communication between the resident and his daughter.Ethical IssuesHealth care providers have a moral obligation to do good and protect patients from harm, including harm to oneself. On the other hand, a person who possesses decision-making capacity has a right to autonomy, including being able to make decisions on his or her own behalf and to refuse treatment, even if it results in self-harm. The state also imposes a duty of reporting, which may be considered doing good, even though it has at least some potential for harm.The reporting requirement is paternalistic and, while well motivated, conflicts with patient privacy and autonomy. It also might make it more difficult for a physician to avoid being fired by the patient that he or she is trying to protect. Nevertheless, reporting requirements generally are considered necessary and desirable, if insufficient, to protect vulnerable individuals from abuse, neglect, or exploitation by caregivers and to hold perpetrators to account.With regard to established patterns of even violent behavior between otherwise competent adult family members, it becomes more difficult from a moral or ethical issue to single out one adult individual for protection based on age alone, particularly when the victim continues to be a perpetrator.While the possibility exists in this case of the daughter exerting undue influence in an effort to get her father to change his will, coercion also appears to be a family value passed from father to daughter. Even so, the father's insistence that he is not a victim and is in control may represent denial or even diminished mental capacity, at least episodically. Otherwise, to what extent can he or should he be protected from himself? Though it may be required by law, there is little otherwise to be gained by the physician or facility staff to reporting this case to authorities.The main ethical underpinning of health care is beneficence. We must do good. How much good? This particular case notwithstanding, there is significant underreporting of abuse and neglect by physicians and other licensed health care workers. As caregivers or at the very least as people, who care, do we do enough? If so, how can we or others tell?There is a general tendency to set boundaries, to limit our involvement, and to tell ourselves that whatever the problem, it is always someone else's responsibility. We try to convince ourselves that we are limiting our responsibility though, in actuality, we are still responsible for many of the things we may wish we were not. Dr. Evans is a full-time long-term care physician in Charlottesville, Va., and medical director of two skilled nursing facilities. He serves on AMDA's board of directors and Caring for the Ages' editorial advisory board. DiscussionIs this a case of elder abuse? What more should the physician or the facility do about it? Must it be reported?When the physician did tell facility staff and management of the suspicious incidents, they insisted that they were unaware of any instance of physical violence and that none of their licensed staff was aware of any shouting or verbal abuse directed toward their resident. All were painfully aware of the resident's long history of verbal abuse directed at them, however. In the overwhelming majority of states, licensed health care workers are required to report suspected abuse, neglect, or exploitation of seniors to appropriate persons—typically, adult protective services or local law enforcement. An employee of a licensed care facility may generally meet this requirement by reporting it to his or her supervisor, who in turn is obligated to report it to the appropriate agency. A suspicion of abuse, neglect, or exploitation is all that is required for a report, not proof of mistreatment.A health care worker is not required to conduct an investigation. A facility may do so and subsequently decide that no mistreatment occurred. Underreporting is widespread. Reporting by physicians is especially uncommon.In this case, it appears that reporting to authorities would be required, despite the patient's own protestations and the likely negative repercussions from the patient and his family. However, it is unlikely that any meaningful intervention would occur as a result. Is this a case of elder abuse? What more should the physician or the facility do about it? Must it be reported? When the physician did tell facility staff and management of the suspicious incidents, they insisted that they were unaware of any instance of physical violence and that none of their licensed staff was aware of any shouting or verbal abuse directed toward their resident. All were painfully aware of the resident's long history of verbal abuse directed at them, however. In the overwhelming majority of states, licensed health care workers are required to report suspected abuse, neglect, or exploitation of seniors to appropriate persons—typically, adult protective services or local law enforcement. An employee of a licensed care facility may generally meet this requirement by reporting it to his or her supervisor, who in turn is obligated to report it to the appropriate agency. A suspicion of abuse, neglect, or exploitation is all that is required for a report, not proof of mistreatment. A health care worker is not required to conduct an investigation. A facility may do so and subsequently decide that no mistreatment occurred. Underreporting is widespread. Reporting by physicians is especially uncommon. In this case, it appears that reporting to authorities would be required, despite the patient's own protestations and the likely negative repercussions from the patient and his family. However, it is unlikely that any meaningful intervention would occur as a result. Factors in MistreatmentMistreatment may take the form of physical, emotional, or sexual abuse; physical or emotional neglect; or financial exploitation. Because individuals with physical or cognitive impairment, children, and seniors are considered more vulnerable to mistreatment and less able to report it than others, state laws have imposed reporting requirements on licensed health care workers.Aabout half of all cases of elder mistreatment reported to authorities are substantiated by further investigation. Self-neglect is the most common form of mistreatment reported and substantiated. Physical abuse appears to be far less common than neglect. Meanwhile, financial exploitation of seniors appears to be on the rise.Impairments in cognition and function and resultant dependence on others for care are risk factors for elder abuse. The victims of elder abuse and the perpetrators are usually well known to one another if not living together.In addition, individuals who have a history of abuse directed toward their own family members and those with a history of substance abuse are themselves more likely to become victims of elder abuse later in life, often at the hands of the individuals previously abused by those elders. Consequently, in addition to the “caregiver stress” model of elder abuse, a model not unlike abuse among younger individuals is “family violence” elder abuse. In the case described here, a pattern of abuse was established by the father many years ago, and it appears to have long punctuated communication between the resident and his daughter. Mistreatment may take the form of physical, emotional, or sexual abuse; physical or emotional neglect; or financial exploitation. Because individuals with physical or cognitive impairment, children, and seniors are considered more vulnerable to mistreatment and less able to report it than others, state laws have imposed reporting requirements on licensed health care workers. Aabout half of all cases of elder mistreatment reported to authorities are substantiated by further investigation. Self-neglect is the most common form of mistreatment reported and substantiated. Physical abuse appears to be far less common than neglect. Meanwhile, financial exploitation of seniors appears to be on the rise. Impairments in cognition and function and resultant dependence on others for care are risk factors for elder abuse. The victims of elder abuse and the perpetrators are usually well known to one another if not living together. In addition, individuals who have a history of abuse directed toward their own family members and those with a history of substance abuse are themselves more likely to become victims of elder abuse later in life, often at the hands of the individuals previously abused by those elders. Consequently, in addition to the “caregiver stress” model of elder abuse, a model not unlike abuse among younger individuals is “family violence” elder abuse. In the case described here, a pattern of abuse was established by the father many years ago, and it appears to have long punctuated communication between the resident and his daughter. Ethical IssuesHealth care providers have a moral obligation to do good and protect patients from harm, including harm to oneself. On the other hand, a person who possesses decision-making capacity has a right to autonomy, including being able to make decisions on his or her own behalf and to refuse treatment, even if it results in self-harm. The state also imposes a duty of reporting, which may be considered doing good, even though it has at least some potential for harm.The reporting requirement is paternalistic and, while well motivated, conflicts with patient privacy and autonomy. It also might make it more difficult for a physician to avoid being fired by the patient that he or she is trying to protect. Nevertheless, reporting requirements generally are considered necessary and desirable, if insufficient, to protect vulnerable individuals from abuse, neglect, or exploitation by caregivers and to hold perpetrators to account.With regard to established patterns of even violent behavior between otherwise competent adult family members, it becomes more difficult from a moral or ethical issue to single out one adult individual for protection based on age alone, particularly when the victim continues to be a perpetrator.While the possibility exists in this case of the daughter exerting undue influence in an effort to get her father to change his will, coercion also appears to be a family value passed from father to daughter. Even so, the father's insistence that he is not a victim and is in control may represent denial or even diminished mental capacity, at least episodically. Otherwise, to what extent can he or should he be protected from himself? Though it may be required by law, there is little otherwise to be gained by the physician or facility staff to reporting this case to authorities.The main ethical underpinning of health care is beneficence. We must do good. How much good? This particular case notwithstanding, there is significant underreporting of abuse and neglect by physicians and other licensed health care workers. As caregivers or at the very least as people, who care, do we do enough? If so, how can we or others tell?There is a general tendency to set boundaries, to limit our involvement, and to tell ourselves that whatever the problem, it is always someone else's responsibility. We try to convince ourselves that we are limiting our responsibility though, in actuality, we are still responsible for many of the things we may wish we were not. Health care providers have a moral obligation to do good and protect patients from harm, including harm to oneself. On the other hand, a person who possesses decision-making capacity has a right to autonomy, including being able to make decisions on his or her own behalf and to refuse treatment, even if it results in self-harm. The state also imposes a duty of reporting, which may be considered doing good, even though it has at least some potential for harm. The reporting requirement is paternalistic and, while well motivated, conflicts with patient privacy and autonomy. It also might make it more difficult for a physician to avoid being fired by the patient that he or she is trying to protect. Nevertheless, reporting requirements generally are considered necessary and desirable, if insufficient, to protect vulnerable individuals from abuse, neglect, or exploitation by caregivers and to hold perpetrators to account. With regard to established patterns of even violent behavior between otherwise competent adult family members, it becomes more difficult from a moral or ethical issue to single out one adult individual for protection based on age alone, particularly when the victim continues to be a perpetrator. While the possibility exists in this case of the daughter exerting undue influence in an effort to get her father to change his will, coercion also appears to be a family value passed from father to daughter. Even so, the father's insistence that he is not a victim and is in control may represent denial or even diminished mental capacity, at least episodically. Otherwise, to what extent can he or should he be protected from himself? Though it may be required by law, there is little otherwise to be gained by the physician or facility staff to reporting this case to authorities. The main ethical underpinning of health care is beneficence. We must do good. How much good? This particular case notwithstanding, there is significant underreporting of abuse and neglect by physicians and other licensed health care workers. As caregivers or at the very least as people, who care, do we do enough? If so, how can we or others tell? There is a general tendency to set boundaries, to limit our involvement, and to tell ourselves that whatever the problem, it is always someone else's responsibility. We try to convince ourselves that we are limiting our responsibility though, in actuality, we are still responsible for many of the things we may wish we were not. The CaseThe physician of an 83-year-old assisted living resident was contacted by the patient's acquaintance. She informed the doctor that the patient's daughter had slapped her father's face in the facility's dining room while they were eating. Facility staff were not aware of the incident.The patient was wheelchair bound as a result of parkinsonism, osteoarthritis, and a prior stroke but had seemingly normal cognitive function. A retired executive and divorced father of two adult children—a son and a daughter—he had a history of alcoholism and had been verbally and physically abusive to his family in the past. For many years, he was estranged from his children. In recent years, however, he had attempted to reconcile with them.The children did not get along with each other, but both expressed a desire to reconcile with their father in his waning years. During frequent visits with his physician, he often remarked about how important his children were to him. He expressed remorse over how he treated them in the past. Nevertheless, visits with his children often culminated with him verbally abusing them.He had been a resident at the same facility for the past 5 years. For want of companionship and control, he employed private duty sitters 24 hours a day, whom he often verbally abused and threatened to fire. Consequently, they frequently quit. He employed an administrative assistant who hired the sitters and managed scheduling. She took shifts herself when sitters did not show up for work or quit.His daughter became particularly attentive to him when his health took sudden downturns from acute illness. Often when she visited, she would excuse the sitters from his room. Not infrequently, the sitters reported to the administrative assistant that they heard the father and daughter shouting at each other behind closed doors. The administrative assistant reported that the daughter often asked her father for money and encouraged him to change his will.With regard to the alleged face slap, the occasion was one in which both children were dining with the patient in the facility's private dining room. The physician contacted the patient's son, who described the incident in detail. There was no slap, he said. Rather, the daughter verbally remonstrated with her father when he became offensive, and she “patted” his forearm. The son made a point of saying that he would be first to call the police if his sister's behavior constituted physical abuse.The physician questioned his patient about the incident and about his daughter's behavior. Did she hit him? Did he feel safe? Was she trying to get him to change his will? The patient assured the physician that the slap on the wrist from his daughter was nothing, that their relationship had always been tempestuous, and that she had gotten better.Moreover, he considered it his life's unfinished business to reconcile with his children and to encourage them to get along with one another before he died. He and his daughter did discuss his will often. He was insulted by the suggestion that she was trying to control him. He became adamant that he would not cooperate with any investigation by adult protective services. The physician of an 83-year-old assisted living resident was contacted by the patient's acquaintance. She informed the doctor that the patient's daughter had slapped her father's face in the facility's dining room while they were eating. Facility staff were not aware of the incident. The patient was wheelchair bound as a result of parkinsonism, osteoarthritis, and a prior stroke but had seemingly normal cognitive function. A retired executive and divorced father of two adult children—a son and a daughter—he had a history of alcoholism and had been verbally and physically abusive to his family in the past. For many years, he was estranged from his children. In recent years, however, he had attempted to reconcile with them. The children did not get along with each other, but both expressed a desire to reconcile with their father in his waning years. During frequent visits with his physician, he often remarked about how important his children were to him. He expressed remorse over how he treated them in the past. Nevertheless, visits with his children often culminated with him verbally abusing them. He had been a resident at the same facility for the past 5 years. For want of companionship and control, he employed private duty sitters 24 hours a day, whom he often verbally abused and threatened to fire. Consequently, they frequently quit. He employed an administrative assistant who hired the sitters and managed scheduling. She took shifts herself when sitters did not show up for work or quit. His daughter became particularly attentive to him when his health took sudden downturns from acute illness. Often when she visited, she would excuse the sitters from his room. Not infrequently, the sitters reported to the administrative assistant that they heard the father and daughter shouting at each other behind closed doors. The administrative assistant reported that the daughter often asked her father for money and encouraged him to change his will. With regard to the alleged face slap, the occasion was one in which both children were dining with the patient in the facility's private dining room. The physician contacted the patient's son, who described the incident in detail. There was no slap, he said. Rather, the daughter verbally remonstrated with her father when he became offensive, and she “patted” his forearm. The son made a point of saying that he would be first to call the police if his sister's behavior constituted physical abuse. The physician questioned his patient about the incident and about his daughter's behavior. Did she hit him? Did he feel safe? Was she trying to get him to change his will? The patient assured the physician that the slap on the wrist from his daughter was nothing, that their relationship had always been tempestuous, and that she had gotten better. Moreover, he considered it his life's unfinished business to reconcile with his children and to encourage them to get along with one another before he died. He and his daughter did discuss his will often. He was insulted by the suggestion that she was trying to control him. He became adamant that he would not cooperate with any investigation by adult protective services.