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  • Sue C. Jacobs, Ph.D. Ledbetter Lemon Counseling Psychology Diversity Professor School Of Applied Health & Educational Psychology; College Of Education; Oklahoma State University Ethical Considerations in Clinical Practice with Older Adults and Geriatric Patients Friday, March 15, 2012 Northeastern Psychology Internship Program CEU Workshop, Tulsa, Oklahoma
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  • Todays Objectives Todays Objectives Understand importance of competencies in working with diverse older adults and geriatric patients as ETHICAL RESPONSIBILITY; Identify some key ethical issues arising in clinical practice with older adult clients and geriatric patients, their families, communities, and systems of care; Identify and discuss applicable APA Principles and Codes as examples; Understand importance of ethical decision making
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  • Presentation Outline Overview of Aspirational Ethical Principles Competency, including multicultural competency, necessary to be ethical clinical practitioner Who are we talking about as older adults and geriatric patients? And, who else? Population trendsthe aging tsunami and increasing diversity Common ethical concerns in working with older adults and geriatric patients Ethical decision making model
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  • Differing Professional ethics codes Have Similar Aspirational Principles Psychologists Neurologists Neuropsychologists Pharmacists Social workers Dentists Counselors Psychiatrists Physical Therapist DHS workers Physicians Geriatricians Family Community Caregivers Spiritual/Religious Leaders Nurses Other Allied Health Providers Health Systems: Hospitals, Adult Day Centers, Home Care, Nursing Homes, Community Centers Educational Systems Hospice providers
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  • General Principles of the Ethics Code of American Psychological Association Beneficence and Nonmaleficence Fidelity and Responsibility Integrity Justice Respect for People's Rights and Dignity
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  • General Principles of the Ethical Principles of Psychologist and Code of Conduct (2002, including 2010 Amendments): px# px# Principles are aspirational in nature, not enforceable
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  • Principles to Guide your practice and Ethical Decision Making Nonmaleficence (Do no harm/minimize harm) Beneficence (do good) However, the Nonmaleficence trumps any desire to be helpful or do good
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  • Clients/Patients may be individuals, their families, friends, other health care providers, their communities, clergy, healers .. Fidelity and Responsibilty: Whom entrusts us to provide ethical care and to whom are we responsible?
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  • Integrity Promote accuracy, honesty, truthfulness Keep promises and avoid unwise commitments Consider integrity also when considering whether interventions used are based on latest evidence (often issue for older adults as they are excluded from many clinical trials)
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  • Give equal access, be aware of own biases, and limits of competence Justice Recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures and services being conducted by psychologists. Exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence and the limitations of their expertise do not lead to or condone unjust practices.
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  • Especially important with increasingly diverse older clients/geriatric patients Respect for People's Rights and Dignity respect dignity and worth of all people, & the rights of individuals to privacy, confidentiality, & self-determination aware that special safeguards may be necessary to protect the rights & welfare of persons or communities whose vulnerabilities impair autonomous decision making aware of & respect cultural, individual & role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language & socioeconomic status and consider these factors when working with members of such groups. try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.
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  • Key Ethical Issues and Dilemmas in Mental Health Practice With Older Adults Clinical competence to work with older adults Multicultural competency Multiple Relationships Confidentiality Issues of Consent Relationships with other professionals
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  • Competency KNOWLEDGE AWARENESS SKILLS What Competencies are needed for ethical practice with older clients? Geriatric patients? Others in their lives, communities, and systems of care?
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  • AWARENESS To be multicultural competent must be aware
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  • What are your identities? Your clients/patients identities? IdentitiesIdentities Continued Gender Race(s) Ethnicity/Country of Origin Religion/Spirituality Sexual Orientation SES/Education/job Language Health Status/Ability Rural/Urban Age Living situation Who do you consider family Cohort history In relationship to others or ???
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  • What are your Values and World views? ValuesWorldviews What are your top Five values? What about money, status? Wisdom? The earth? ETC ??? Views on life and death Views on older adults and aging Views on community/ family vs individuals in decision making Views on roles ETC.???
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  • What are your clients/patients families values and world views? WHAT ARE YOUR WORLD VIEWS? VALUES THOSE OF OTHERS ON YOUR TREATMENT TEAM? CARE SYSTEMS? REGULATORYAGENCIES? About death and dying? About measures to patients them alive? About who can decide for clients/patients if they are incapacitated or unable to decide? About health and wellness and medicine and mental health? What do your clients/patients value? About where and with whom they live and love? About religion? Education? Government? Institutions? ETC?
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  • AGEISM: What are your views? Ageism affects health care practice. 35% of physicians erroneously consider an increase in blood pressure to be a normal process of aging; 60% of older adults do not receive recommended preventive services; and only 10% receive appropriate screening tests for bone density, colorectal and prostate cancer, and glaucoma (International Longevity Center, 2006). Mental health professionals have historically displayed "professional ageism" with doubts about psychological change or the benefits of therapy in later life. Ageism can translate into a providers feelings of hopelessness and pessimism with the expectation of poor progress creating self-fulfilling prophesies and poor the over-estimation of late life depression by many health providers who work with older adults (Lichtenberg, 1998). It has been identified as a reason why providers underestimate suicide risk in older patients.
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  • MARGINALIZATION Marginalizationthe process by which individuals or social groups are overtly or covertly excluded and relegated to a lower social standing Examples??
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  • STIGMA StigmaA mark, symbol, or other indication of deficiency, disgrace or infamy that identifies a person as having an undesirable condition. Examples???
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  • EXCESS DISABILITY Excess disabilityrefers to discrepancy in expected level of functional ability among older people with severe and persistent medical or mental disorders given the severity or stage of their illness.
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  • Standard 2 of APA Ethics Code Work only within boundaries of competence based on education, training, supervised experience, consultation, study or professional experience Where scientific or professional knowledge established that factors associated with age and other diversities is essential for effective implementation of their services, psychologists have or seek training. experience, consultation, supervision, or make appropriate referrals
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  • Standard 2 of APA Ethics Code When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation or study.
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  • KNOWLEDGE To be culturally competent must have knowledge of the individuals and communities with who you work Who are we talking about as older clients, geriatric patients, others in their systems of care and communities, and in what contexts?
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  • A Few Relatives in their 90s,late 80s, 60s, late 50s and younger: What is Old Old?
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  • Client may be individuals, their families, friends, other health care providers, DHS workers, their communi