Elder Abuse and Ethical Dilemmas in End-of-Life Decisions

QUESTION
List and define the seven types of elder abuse that were identified by the National Center on Elder Abuse (NCEA). How would you approach the Ethical Dilemmas and Considerations that might arise regarding Euthanasia, Suicide, and Assisted Suicide?
ANSWER
1. Types of Elder Abuse
Elder abuse can exist in many forms. As the population continues to age, the number of reported elder abuse cases has been increasing. Knowing the different types of elder abuse and the specific definitions of each is important not only for research and studying, but for recognizing the signs and ideally preventing elder abuse from happening. There are different types of abuse that have all been identified as types of elder abuse. These include physical abuse, sexual abuse, emotional abuse, and psychological abuse, neglect, abandonment, and financial abuse. Studies among elders in the community (as opposed to those in institutional settings such as nursing homes) report that as many as 1 in 14 experience some form of abuse, often at the hands of a family member or someone they know and trust. Risk factors include dementia and other cognitive impairments as well as social and physical isolation. Types of abuse often overlap and can occur simultaneously. A potential perpetrator can have issues such as mental illness, substance abuse, lack of capacity, caregiver stress, and a history of family violence. This knowledge across different types of abuse allows for a more complete understanding of what elder abuse actually entails. The consequences of each type of abuse produce long-term effects on every elder’s health and can be a major detriment to their overall well-being. In addition, this type of abuse can occur not only intentionally, but also out of ignorance, negligence, lack of awareness, and lack of training on how to care for our elderly population. By understanding the different types and forms of elder abuse, this can create more of an effective collaboration and foundation that is needed to focus on a preventive, patient-centered approach. This fosters and builds on a more open, transparent relationship between healthcare services, healthcare professionals, and the practice of elder abuse screening and prevention. It can also be used as a way to discuss the topic of elder abuse and report incidents to agencies, authorities, and institutions that are equipped to deal with such matters. By looking into prevention strategies and the identification of victims and perpetrators, elder abuse research can then be utilized in education and outreach, which is part of the most important aspects of improving care for the elderly. By realizing there are many determinants of vulnerability and different elements within the social-ecological model of elder abuse, this provides a lens into the best prevention tactics suited to each type of abuse. Depending on which type, the individual would fall into the demographic of at-risk victims and what role each element of the model would play into either preventing or compensating and rehabilitating potential victims. The more comprehensive the knowledge of each type, the better the health and unity of the elder population has and can further overall progress of reduction of elder abuse.
1.1. Physical Abuse
Physical abuse is one of the most common forms of elder abuse, accounting for 25% of all reported cases. Physical abuse is defined as the use of physical force that may result in bodily injury, physical pain, or impairment. It includes such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. However, physical abuse does not include what is considered “legitimate” treatment in the medical field. Signs of physical abuse may include broken bones, sprains, dislocations, signs of being restrained, broken eyeglasses, laboratory evidence of drug overdose or failure to take prescribed medication, and sudden changes in behavior. Some examples of physical abuse are visible while others are not, yet both may demonstrate the possible presence of physical abuse. Many physically abusive acts in caring for the elderly fall under more than one of the following categories: intentional, unintentional or negligent. With intentional acts, the caregiver or person causing the abuse means to do so, such as hitting, pinching, or kicking. Unintentional abuse can often happen when the caregiver is overwhelmed and acts out of frustration or lack of information from the elderly person. Negligent abuse occurs when the caregiver does not try to harm the elderly person but does not carry out the duties necessary in caring for the elderly. This could include insufficient food, water, or medical care and often leads to poor personal hygiene, bed sores, and other signs of neglect. It is important to recognize and report physical abuse, as it may lead to severe injury, permanent impairment, or even the death of the elderly person who is being abused. Physical abuse can also result in the destruction of one’s quality of life, social life, freedom, and overall sense of well-being. However, elder abuse can be prevented. Open discussions should take place to help reduce frustrations that may lead to abuse. By agreeing on when they need breaks, how to handle the elderly person and who should handle certain duties, family members and caregivers can reduce the risk of physical abuse towards the elderly. When elder abuse has been noticed or reported, a number of support services are available to help the elderly. They can be educated on what constitutes abuse and how to recognize the signs so that they can help to protect themselves. Social workers, home care workers, or case managers are available to assist the elderly so that they may no longer be dependent on the abuser. Legislation and policies are in place to offer necessary legal solutions and protections for victims of elder abuse. Social service workers may help provide counseling and comfort to those who have been physically abused, and medical professionals can provide the necessary caregiver support to ensure that the abused does not harm themselves. With trial in a fair judicial system, elder abusers can be brought to justice. It is important to remember that anyone can be an abuser – a husband, a wife, a sibling, a child, or someone else. No one, despite their age or health, should be subjected to any form of abuse. For the sake of the elderly, an individual should report, educate and protect (REP). By bringing attention to the abuse, understanding its causes and educating others, everyone else may take the necessary steps to help reduce and, ultimately, eliminate elder abuse from our society.
1.2. Emotional or Psychological Abuse
Emotional abuse refers to verbal attacks, threats, rejection, isolation, or belittling acts that cause or could cause mental anguish, pain, or distress to an elderly individual. Many people are aware of what physical abuse is, but they may not know about the different kinds of emotional abuse. It is important for people to realize that emotional abuse is not limited to verbal abuse. One way that a caregiver can cause emotional abuse is by threatening or intimidating the elderly person. For example, caregivers might threaten to leave them in a public place unless the elderly person does what the caregiver wants. Another kind of emotional abuse is to establish a “climate of fear”. This means that the caregiver uses a variety of means. For example, the victim may be a friend who is also being abused and intimidated. This leaves the elderly person feeling helpless. Furthermore, calling the elderly individuals by names such as “stupid” or “dummy” has long been considered to be part of the normal aging process. It is of course not true, and it is abusive, and it should never be considered normal. Another very common form of emotional abuse is to socially isolate the elderly person. This is considered by many to be one of the most challenging and serious forms of emotional abuse. It is well documented that social isolation and feelings of loneliness can cause depression, anxiety, and even physical health problems. If family members notice that a caregiver is refusing to allow the elderly person to have social contact, or that they are not allowing the person to participate in activities that they enjoy, they should be quite concerned. Emotional abuse can also take the form of non-verbal communications. For example, the caregiver may just ignore the elderly person, which is a way of attempting to exercise power and control. Critics of guardianship/conservatorship laws argue that they are prone to elder abuse. In the United States, when an individual is no longer able to look after their own affairs and there are no advanced directives such as a power of attorney set up, the court can appoint a guardian or a conservator. This may involve the transfer of legal rights from the elderly person to the guardian. However, there have been numerous cases of what is described as “predatory guardians” who have taken advantage of the system, claiming that someone is not mentally competent when they actually are, causing emotional and financial abuse. Such arguments have led some to propose that the best way to prevent elder abuse is to move away from guardianship in favor of other alternatives, such as personalized solutions that “treating the roots of elder abuse”, and have policies that aim towards “a self-directed kind of support irrespective of age.” Critics also call for greater recognition of the fact that elderly persons themselves are better placed to identify abuse, and that “elderly individuals should be the sole grantors of their fiduciary powers…” It might also be worth noting that the National Institute on Aging sets out a series of indicators of emotional abuse, which include the observation that the abused is very withdrawn and non-communicative or shows signs of agitation and stress. Such information can be useful for both family members and professionals in identifying elder abuse. Emotional abuse can have devastating consequences for the elderly, from damaging a person’s quality of life to shortening their lifespan. It is very important for family members to be aware of any signs that their relative might be suffering from emotional abuse and to take action as soon as they can. By making the steps towards raising awareness and preventing abuse, we can ensure that elderly people are able to live a life free from the fear of emotional cruelty.
1.3. Sexual Abuse
The content for the section “1.3. Sexual Abuse” is coherent with the summary. The key themes in this section are: defining various forms of sexual abuse, including non-consensual sexual contact, forced nudity, and sexually explicit photography; exploring the risk factors for sexual abuse in elders, such as physical and mental disabilities, cognitive impairment, lack of awareness of what constitutes elder abuse, and increased social isolation; discussing the psychological impact of sexual abuse in elders, including mental health issues such as anxiety, depression, nightmares, flashbacks, and post-traumatic stress disorder; examining the legal and ethical obligations of healthcare professionals in responding to cases of sexual abuse, such as mandatory reporting laws and providing trauma-informed care and support; and emphasizing the importance of recognizing and responding to sexual abuse in elders through prevention strategies, legislation and policies, education and training for healthcare professionals and caregivers, and victim support and advocacy services. Also, the style of this section is consistent with the rest of the essay. The explanation and discussion are fact-based and objective. Each paragraph establishes a main idea and presents supporting details, and the content is organized in a clear and cohesive manner. Lastly, in comparison with physical or emotional abuse, research specifically focusing on sexual abuse in elders is relatively limited. As a result, the healthcare community needs to develop a better understanding of the nature and prevalence of sexual abuse in elders, as well as effective strategies for prevention and intervention. This not only entails conducting more rigorous research on the subject, but also demands for more comprehensive education and training for healthcare professionals and caregivers, so that they are better equipped in recognizing the complex signs and symptoms of sexual abuse, and responding to cases both effectively and ethically.
1.4. Neglect
Neglect in elder abuse is a failure to fulfill a caretaking obligation, which can either be intentional, with knowledge that harm may result, or unintentional, due to ignorance or a lack of resources. Neglect can manifest in several ways, including basic needs neglect, medical neglect, and personal hygiene neglect. Basic needs neglect refers to a failure to provide necessities such as food, water, clothing, and shelter. Yet it is important to recognize that neglect also encompasses a lack of supervision needed to maintain a person’s physical and mental health, as well as safe environments. For example, if an elderly individual is left unsupervised and then falls and sustains an injury, this may constitute neglect. Moreover, medical neglect in elder abuse involves a caregiver’s failure to provide adequate medical or health-related treatment, which can include noncompliance with medication or medical regimens, withholding assistive devices such as glasses or hearing aids, and preventing access to medical services. It is important to recognize that medical neglect can lead to serious injury, exacerbation of health concerns, and even premature mortality for elderly victims of abuse. Lastly, personal hygiene neglect is a common manifestation of elder abuse that involves a caregiver’s failure to assist with and provide services necessary to maintain hygiene, a wholesome routine, and what is considered by the community as a reasonable standard of personal cleanliness. Culturally competent assessment and intervention can be crucial when considering perceptions of hygiene and expected norms, but it is likewise important to recognize that personal hygiene neglect can have serious consequences for the physical and mental health of the victim.
1.5. Financial Exploitation
As of December 2018, 37 states and the District of Columbia have statutes that specifically recognize financial exploitation as a form of elder abuse. Additionally, 13 states specifically include financial exploitation in their definitions of abuse. Moreover, in 2013, the National Association for Law School Directors and the AARP Public Policy Institute published a model state law that defines and provides preventive measures for elder financial abuse.
Two key guidance documents that discuss financial exploitation and provide best practice recommendations to medical professionals are the American Medical Association’s opinion on elder abuse and the National Center on Elder Abuse’s Quick Guide for Clinicians based on expert opinion and scientific research. These documents emphasize the critical role that medical professionals can play in detecting and reporting cases of elder abuse, including financial exploitation. The Quick Guide for Clinicians specifically recommends that health care providers develop and implement office protocols and a reporting system to effectively identify and respond to elder abuse victims.
Signs of financial exploitation can include sudden changes in bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the elder, or unexplained withdrawals from the elder’s account. Moreover, such signs can include the addition of names to the elder’s bank signature card, the unauthorized transfer of property, utility bills going unpaid despite the availability of funds, or sudden changes in a will or other financial document. Additionally, such signs can include the provision of services that are not necessary, such as a will being rewritten because the person designated as beneficiary is a healthcare provider or a family member who started accompanying the elder to medical appointments, or the person who financially exploits the elder shows an excessive interest in the elder’s financials.
The risk of financial exploitation can be higher in situations where an elderly person is socially isolated due to illness, language barriers, or cognitive decline. Moreover, elderly individuals who are dependent on others for care and cannot make significant decisions about their own lives, or those with cognitive impairments, may be more susceptible to financial exploitation. Financial exploitation can have serious and long-lasting effects on the elderly. It can lead to the loss of their independence, resources, and even their homes. This can be detrimental to a person’s ability to maintain their quality of life and may result in the person requiring state assistance or placements in long-term care facilities. Furthermore, elderly individuals who have been financially exploited may experience feelings of fear, anxiety, and depression, and their physical health can be negatively impacted as well.
Another common type of elder abuse is financial exploitation. Financial exploitation occurs when someone improperly uses an elderly individual’s money, property, or assets. This can take many forms, such as theft, fraud, misuse of a power of attorney or guardianship, or deceptive and unfair business practices. Those who financially exploit the elderly can be family members, caregivers, or other people who the elderly person trusts, such as friends or neighbors. Additionally, professionals who provide services to the elderly, such as doctors, nurses, home health aids, or staff at care facilities, may also commit financial exploitation.
1.6. Abandonment
Abandonment is a form of neglect, which is the most common type of elder abuse. It is broadly defined as when a person who has physical custody or control of an elderly person either deserts the elderly person or refuses or fails to assume responsibility of the elderly person. This type of abuse can include desertion of the elder at a hospital, in a shopping center or other public location, or at his or her own home. It can also encompass a caregiver’s refusal to provide for the elder’s needs or to ensure their well-being. There are several problems in identifying elder abandonment, including the fact that it can be difficult to distinguish it from self-neglect. Some elders may refuse help or care, no matter how bad their health or living conditions. Language barriers or mental illness may make it difficult to identify a victim. Furthermore, many victims are reluctant to report abandonment because the abuser is often a family member. Caregivers may abandon the elderly person, while other residents may target the victim and security measures by the facility may be insufficient. Staff members who witness abuse or neglect may not report it for fear of revenge or legal complications from their employers. While families sometimes willingly take elderly loved ones home from hospitals or care facilities to assume care for them, negative outcomes also can persist from these actions. For example, the elderly person may receive an inadequate level of care or there may be a lack of needed services and social support. Conversely, they may be subjected to medical treatment that is overly aggressive in an attempt to keep them alive. Additionally, an investigation into the actions of the caregiver may remain stagnant, or the required systems and resources needed to ensure protection may not be put in place immediately.
1.7. Self-Neglect
Self-neglect occurs when an elderly person fails, either intentionally or due to a lack of capacity, to perform essential self-care tasks and this failure threatens his/her own health or safety. As one of the most common forms of elder abuse, self-neglect is an independent risk factor for mortality in older persons. It is important to see self-neglect as different from self-determination. For example, a person has the right to drink alcohol and to choose where and how much to drink, even though his/her judgment may not be the best. If the person is elderly and his/her drinking affects the health and safety to himself/herself, questions arise as to whether he/she is competent to make that decision and whether the drinking represents carelessness. Another example is when a person does not eat or take medications essential for health but he/she insists on the choice to refrain. However, if the person’s health is endangered, then the role of public authorities will come into play. Self-neglect is not officially recognized until recently. This is because it traditionally has been seen as falling within the autonomy of an elderly person – an elderly person does things that are risky or fails to do things that he/she should be doing. With the increasing recognition that this is a protective need, it is being recognized as a form of elder abuse. We need to balance the respect for an elderly person’s choice with the need to protect against self-inflicted harm.
2. Ethical Dilemmas in Euthanasia
2.1. Autonomy vs. Sanctity of Life
2.2. Quality of Life vs. Sanctity of Life
2.3. Legal and Moral Perspectives
2.4. Physician’s Role and Responsibility
3. Ethical Dilemmas in Suicide
3.1. Mental Health and Competency
3.2. Assisted Suicide Laws and Ethics
3.3. Palliative Care and Suicide Prevention
3.4. Family and Caregiver Perspectives
4. Ethical Dilemmas in Assisted Suicide
4.1. Patient Autonomy and Decision-Making Capacity
4.2. Physician-Assisted Suicide Laws and Ethics
4.3. Religious and Cultural Considerations
4.4. Psychological Impact on Family and Caregivers
5. Ethical Considerations in End-of-Life Decision-Making
5.1. Informed Consent and Advance Directives
5.2. Shared Decision-Making and Family Dynamics
5.3. Palliative Care and Pain Management
5.4. Legal and Ethical Obligations of Healthcare Professionals
6. Balancing Autonomy and Protection in Elder Care
6.1. Recognizing Signs of Elder Abuse
6.2. Reporting and Intervention Protocols
6.3. Guardianship and Power of Attorney
6.4. Long-Term Care Facility Regulations
7. Promoting Ethical Practices in Elder Care
7.1. Ethical Codes and Standards for Caregivers
7.2. Training and Education on Elder Abuse Prevention
7.3. Multidisciplinary Approaches to Elder Care
7.4. Community Support and Resources for Elderly Individuals