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

Today’s 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

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 trends—the aging tsunami and increasing diversity

Common ethical concerns in working with older adults and geriatric patients

Ethical decision making model

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

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

General Principles of the Ethical Principles of Psychologist and Code of Conduct

(2002, including 2010 Amendments):

http://www.apa.org/ethics/code/index.aspx#

Principles are aspirational in nature, not enforceable

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”

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?

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)

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.

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.

Key Ethical Issues and Dilemmas in Mental Health Practice With Older AdultsClinical competence to work with older

adults Multicultural competencyMultiple RelationshipsConfidentialityIssues of ConsentRelationships with other professionals

Competency

KNOWLEDGEAWARENESSSKILLS

What Competencies are needed for ethical practice with older clients? Geriatric patients? Others in their lives, communities, and systems of care?

AWARENESS

To be multicultural competent must be aware

What are your identities? Your clients’/patients’ identities?

Identities Identities Continued

GenderRace(s)Ethnicity/Country of

OriginReligion/SpiritualitySexual OrientationSES/Education/jobLanguageHealth Status/Ability

Rural/UrbanAgeLiving situationWho do you consider

familyCohort history…In relationship to

others or ???

What are your Values and World views?

Values Worldviews

What are your top Five values?

What about money, status?

Wisdom?The earth?ETC ???

Views on life and deathViews on older adults

and agingViews on community/

family vs individuals in decision making

Views on rolesETC.???

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?

IMPORTANT TO CONSIDER IN PROVIDING CULTURALLY COMPETENT BEHAVIORAL HEALTH CARE TO OLDER ADULTS

AGEISMDIVERSITYMARGINALIZATIONSTIGMA EXCESS DISABILITY

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 provider’s 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.

MARGINALIZATION

Marginalization…the process by which individuals or social groups are overtly or covertly excluded and relegated to a lower social standing

Examples??

STIGMA

Stigma…A mark, symbol, or other indication of deficiency, disgrace or infamy that identifies a person as having an “undesirable” condition.

Examples???

EXCESS DISABILITY

Excess disability…refers 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.

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

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.

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?

A Few Relatives in their 90s,late 80s, 60s, late 50s and younger: What is Old Old?

Client may be individuals, their families, friends, other health care providers, DHS workers, their communities, clergy, healers, a treatment team…..

Some Key points: Demographic diversity in older adults and aging U.S. population

As we age we are more heterogeneous

Racially & ethnically diverse older adults are more likely to live in poverty

Many health care disparities stemming from non-majority status

Increased impact of mind body, etc.

Need to be prepared as ethical health service providers to address needs and strengths of a diverse older adult population: age, race, ethnicity, country of origin, religion, disability/ ability, gender, sexual orientation, rural/urban; social economic status

Context of Ethical Clinical Practice: Aging Tsunami

Demographic data highlight the increasing diversity of our aging population, a group that defies simple characterization and encompasses divergent historical, social and cultural experiences.

This is in addition to other increasing individual differences in health/mental health and illness in the aging process and the increasing interaction of mental, physical, social, spiritual, economic, etc. systems in older individuals.

Who are we talking about in terms of diverse older adults?

Approximately 35 million Americans now age 65 or older and about 7 million are members of racial/minority groups (US Census, 2007); 19.3 % are racial or ethnic minorities (Administration on Aging [A0A], 2008)

Ethnic/racial minority rates of growth are expected to exceed those of Caucasians over the next 50 years. Between 2007 and 2030, the White population 65+ is projected to increase by 68% compared with 184% for older minorities, including Hispanics (244%), African-Americans (126%), American Indians, Eskimos, and Aleuts (167%), and Asians and Pacific Islanders (213%) (AOA, 2008).

More demographics to ponder

There is much diversity within racial/ethnic groups◦ Consider that Asian Americans comprise 26-census-defined

sub-ethnic groups. ◦ Consider multiple American Indian tribes, rural, urban,

reservation-based, non-reservation based, and community histories.

◦ Consider 3 million foreign-born persons 65 years of age or older in the U.S., more than 1/3rd born in Europe, 1/3rd in Latin America, and 1/4th in Asia. In the future, increasing numbers of foreign-born older adults will likely be from Latin America and Asia (He, 2002). In 2050, 16 million of the projected 81 million elderly will be foreign born (Pew Center, 2008).

More demographics to consider: Gender

Older women make up 58 % of the U.S. population aged 65 years and over, 69 % of those aged 85 years and over, and 80 % of those aged 100 years and over. The U.S. Census Bureau projects that by 2030, the number of women aged 65 years and over will double to 40 million (U.S. Census Bureau Population Division, 2006).

Transgender: Paraphrased Statement made by Grandmother of legal, political transgender movement—” in nursing homes, they only look below the neck. I’d rather die than go to a nursing home if my partner dies first.”

The intersection of race, ethnicity and poverty can account for increased disability. Mental disabilities in late life are also on the rise, as the number of people with severe and persistent mental illnesses are receiving better healthcare overall and are living longer than in the past (e.g. Palmer, Heaton & Jeste, 2004).

Income…

While most are not poor, there are a significant number of older Americans living below the poverty line - 3.4 million older persons - and an additional 2.2 million “near poor.”

Racially/ethnically diverse older adults experience poverty at a disproportionate rate

Religious diversity…

Religious beliefs and behaviors are an important consideration when working with older people and their families.

As Diane Eck (2001) of the Harvard Pluralism Project noted, the US has become the most religiously diverse nation in the world. In recent years, Muslims, Hindus, and Buddhists, and followers of many other religions have arrived here from every part of the globe, radically altering the US religious landscape.

Religious diversity issues…

Many older adults attach a high value to their religious beliefs and behaviors

In addition to church attendance, this participation may include reading religious materials, watching television programs, listening to religious music, and engaging in private prayers or meditation and other spiiritual practices.

Since religious/spiritual traditions and beliefs affect views about birth, life, and death, providers of behavioral health services need to have an understanding of these traditions

:

Culturally diverse older adults often at high risk for illness

Culturally diverse older Americans often are at greater risk of poor health, social isolation, and poverty, than are their younger counterparts. Evidence of racial and ethnic disparities can be found across a broad spectrum of health conditions and outcomes. Excessive deaths and excess morbidity and disability are prevalent among racial and ethnic minority elders.

Older adults with an LGBT identity, the challenges are many, including poorer health care, and securing reasonable housing, and caregiving services.

Culturally diverse older adults also often at high risk for mental illness

Racial and ethnic minorities are also overrepresented in many subgroups at high risk for the development of mental illnesses, and have less access to mental health services than Whites, are less likely to receive needed services, and often receive a lower quality of care.

Older adults often fail to recognize and link psychological or physical symptoms with mental health problems or illness, resulting in a lower quality of life This burden is increasing as barriers to care have not diminished.

Health Literacy

Problems with basic literacy: Two-fifths of older adults read at basic level of literacy

Problems with health literacy: Half of older adults have significant problems in understanding health care options

Less education, problems in language proficiency tied to problems in health literacy proficiency

WHAT ABOUT AGING AND DIVERSITY IN YOUR WORK SETTING? Tulsa?? Oklahoma??What about your biases/assumptions?

Key Ethical Issues and Dilemmas in Mental Health Practice With Older AdultsClinical competence to work with older

adults Multicultural competencyMultiple RelationshipsConfidentialityIssues of ConsentRelationships with other professionals

Additional ethical (and legal) issues/dilemmas In providing clinical services to older adultsAssessing older adult’s physical and cognitive

competence and ability to make decisionsIssues of older adults’ physical and psychological

safetyIssues of abuse and neglectHigh stigma associated with mental health

concerns and cognitive decline, especially in rural areas

Advocacy

Key Ethical Issues and Dilemmas in Mental Health Practice With Geriatric PatientsSame as with older adultsClinical Competence in context of

“Generalist” care and multidisciplinary team/interdisciplinary team care

Multiple Relationships

What are some possible situations and settings you may encounter when working with older adults or geriatric patient?

What about with other professionals?

What about barter?

Issues of Multiple Relationships (and Conflicts of Interest)

Example from APA Code of Ethics (Standard 3.05): “a psychologist refrains from entering into a multiple relationship if themultiple relationship could reasonably be expected to impair thepsychologist’s objectivity, competence, or effectiveness in performinghis or her functions as a psychologist, or otherwise risks exploitation orharm to the person with whom the professional relationship exists.

Multiple relationships that would not reasonably be expected to causeimpairment or risk exploitation or harm are not unethical. (APA, 2002,p. 1065).”

Merely entering into or finding oneself in a multiple relationship does not mean you are acting unethically. Multiple relationships are inevitable, for example, in rural life. The issue is how you manage the relationships.

Confidentiality

What are some situations in which you may encounter an issue of confidentiality in practice with older adults?

With Geriatric Patients?

CONSENT

Many challenges of multiple relationships, confidentiality, and working with other professionals in multiple settings can be handled by a good, comprehensive and mutually informed consent process.

Along with consultation and documentation, informed consent is a foundation of ethical practice and good risk management.

DISCUSS EXAMPLES

Consent

Consent is not just a piece of paper.Necessity for mutual discussion of what

consent is for and in what situationsQuestion of who can consent, competency

to consent, patient or???Consent involves who has access to

information at the time, in case of future inability to consent, also includes other members of health care team

What about consent involving electronic medical records, telehealth, etc.?

Relationships with other professionals

Cooperation with other professionalsDisclosuresConflicts between ethics and law,

regulations, or other governing legal authority

Conflicts between ethics and organization demands

APA Standards 3.09, 4.05, 1.02, 1.03

How address these issues ethically?

Three keys to ethical practice: consent, consultation, and documentation

And, having and routinely following an ethical decision making model

What Can You do?

Issues to consider:

How do you normally make tough ethical decisions?

Do you have a decision making model you follow?

Importance of thinking about the way you make ethical decisions

BECAUSE…

A decision making model can be a roadmap in multiple contexts, something to help avoid pitfalls, dead ends, flat tires, etc and reduce harm and do the good you want to do!

Suggestions to enhance ethical decision making when working with older adults

Consultation with other Professionals (unfortunately not that easy to access in some rural Oklahoma areas but more accessible with internet and telehealth)

Prevention and Positive Practice Model (Adapted from Barnett & Johnson, 2008)—combination of risk-benefit and context of therapy

Prevention and positive practice approach to ethical decision making

Before determining course of professional action, weigh potential risk and benefits

Ask Yourself: “Would a jury of my peers agree that I carefully considered risks and benefits and acted to maximize benefit and reduce harm?”

Try to anticipate how other persons, professionals, or organizations might misuse your work and make every effort to prevent such misuse

Prevention and positive practice approach to ethical decision making

Do Self Care; Take steps to ensure the psychological and physical health does not interfere with your capacity to effectively help those with whom you work

When conflicts arise with clients/patients, their families, other health care providers, organizations, and/or between different elements of the ethics codes you work under, take steps to resolve the conflict while minimizing harm and promoting the best interests of you clients

Again, cultural competence and specific competencies in working with older adults as essential to ethical practice: Knowledge, Skills and Attitudes

What is it in working with increasing diverse and aging population?

Brief review and reflection

KnowledgeAging trends and increasing diversityAttitudes towards mental health and health careResources and/or lack of them

Awareness Of own identities, world view, values own culture Some awareness of diverse group, cohort world

views How become, know about individuals/families/ communities with world views that differ from yours

THANK YOU!Sue C. Jacobs, PhDSchool of Applied Health and Educational Psychology425 Willard Oklahoma State UniversityStillwater, OK 74078-4024405-744-9895 Fax 405-744-6756sue.c.jacobs@okstate.edu

Questions, Comments, Discussion

Resources

Resources

Most of the material in today’s presentation came from or was adapted from “Multicultural Competency in Geropsychology: A Report of the APA Committee on Aging and its Working Group on Multicultural Competency in Geropsychology”

It is available online and includes a useful list of web resources and other publications including those cited within this presentation:

http://www.apa.org/pi/aging/programs/pipeline/multicultural-geropsychology.aspx

Resources

Other useful practice resources can be found at:

American Psychological Association, Public Interest Directorate, Office of Aging, Resources and Publications: http://www.apa.org/pi/aging/resources/index.aspx

I have noted the web link to many resources change frequently…Google and Psychingo and Ageline are helpful in this regard

Selected References

American Counseling Association ACA Code of Ethics 2005. www.counseling.org

American Psychological Association (2002 including 2010 ammendments). Ethical Principles of Psychologists and Code of Conduct/ http://www.apa.org/ethics/code/index.aspx

American Association for Marriage and Family Therapy (2001). AAMFT code of ethics.

Clinical Social Worker Code of Ethics (most recent review, 2006). http://associationsites.com/CSWA/collection/Ethcs%20Code%20Locked%2006.pdf

American Nursing Association. ANA Code of Ethics for Nurses with Interpretative Statements http://www.ana.org/ethics/ecode.htm

American Psychiatric Association. Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry http://www.psych.org/psych.pract/ethics/medicalethics2001 42001.cfm

More References

For other mental health ethics codes, a good source is: http://www.centerforethicalpractice.org

Other referencesAmerican Psychological Association (2004).

Guidelines for psychological practice with older adults. American Psychologist, 19(4), 236-260.

Barnett, J.E. & Johnson, W. Brad (2008). Ethics desk reference for psychologists. Washington DC: APA.

Bocker E, Glasser M., Nielsen K, & Weidenbacher-Hoper V (2012) Rural older adults' mental health: status and challenges in care delivery. Rural And Remote Health, ISSN: 1445-6354, 2012; Vol. 12, pp. 2199; PMID: 23145784

More References

Sanders, G.F., Fitzgerald, M.A., & Bratell, M ( 2008). Mental health services for older adults in rural areas: An ecological systems approach. Journal of Applied Gerontology, 27(3), 252-266.

Werth JL Jr; Hastings SL; & Riding-Malon R (2010) Ethical challenges of practicing in rural areas. Journal Of Clinical Psychology, ISSN: 1097-4679, 2010 May; Vol. 66 (5), pp. 537-48; PMID: 20222121