Ethical Issues & Self-Neglect Considerations

Consent & Capac i ty in Heal thcare Conference

Royal Marine Hote l , Dun Laoghaire , Co. Dubl in

2 nd December, 2015

Dr. Mary Rose Day, DN

Objectives

•Case Study to be presented

•Ethical issues and challenges

•Beneficence and non-maleficence

•Autonomy and capacity

•Model of ethical justification

•Responding best interest for people’s rights and dignity

•Summarise and Conclude

Definitions

•The HSE, Social Care Division, Policy & Procedures considers a vulnerable person as

•“ an adult who is restricted in capacity to guard himself/herself against harm or exploitation or to report such harm or exploitation”.

And

•Self‐neglect as:

•“the inability or unwillingness to provide for oneself the goods and services needed to live safely and independently” (HSE, 2014, p. 44).

Context of Self-Neglect

Self-neglect is associated with:

•Increased use of Emergency Department (ED) services

•Greater self-neglect is associated with increased risk for hospice utilization

•Referral to Adult Protective Services (APS) resulted in:

•Significantly increased risk for Nursing Home Placement Significantly increased mortality, more home visits, but no increase in outpatient or nursing facility services

•Reduction in social and environmental risks.

(Dong & Simon 2008, Dong et al. 2009, 2012, Ernst & Smith 2011, Franzin & Dyer 2008, Lach et al. 2002)

Ethical Issues and Challenges

Beneficence and non-maleficence

Autonomy and Capacity

Risk Factors: Executive Functioning

• Cognitive impairment (e.g., depression, dementia, executive dysfunction)

• Multiple morbidities (cardiovascular disease, hypertension, diabetes,

malnutrition, etc.)

• Poor/reduced social networks, living alone

• Poverty, poor economic circumstances, deprivation

• Traumatic life history (e.g., abuse in early years, bereavement, divorce, chaotic

lifestyles due to mental health issues, and drug or alcohol abuse)

• Poor coping

• Older age and mental status problems strongly associated with global neglect

behaviours

(Bozinovski 2000, Burnett et al. 2006, 2014, Choi et al. 2009, Gibbons 2009, Lauder et al., 2009).

Executive Function and Dysfunction

Executive function (frontal lobe function) is necessary for planning, initiation, organisation, self-awareness and execution of tasks and is critically important for protection and safety and independent living. Executive dysfunction inhibits appropriate decision making and problem solving

(Hildebrand et al. 2013).

Characteristics of Executive Dysfunction

Inability to complete complex cognitive tasks (i.e. managing finances, identifying dangerous situations)

Inability to maintain adequate hygiene or self-administer medications

(Royall et al., 2005, Dyer et al., 2007)

Functional CapacityA functional definition of capacity focuses on a person’s cognitive ability to understand the nature and consequences of a decision in the context of his or her available choices.

Model of Ethical JustificationClient(Self-Neglect)

Values Rules Principles Actions

Being independent living in his own home; Arthurs choice is to remain in current situation

Informed consent must be obtained for a home visit and before executing services.

Respect for autonomy and self-determination

Seeks help for shopping/accessing money/accepts home visits/refuses any interventions/cleaning services

Community Health and Social Care Professionals

-Therapeutic relationship between community health and social care professionals and the client that is based on trust, understanding, compassion, and support serves to empower the client to make life choices.

-Ensures ethical practice of community and social work is embedded in nationaland international codes of ethics.

Informed consent is necessary prior to intervention.

-Respect choice, autonomy, and self-determination. Resolve ambiguity in duty of care/best interest.

-Social Justice (Challenging discrimination, recognising diversity, working in solidarity with team members and challenging unjust policies and practice).

-Multidisciplinary team approach: intervene/duty of care vs do not intervene.

-Whose best interest?What are the risks if we intervene? Do we wait for change in situation?

Day et al, 2015, p.100

Safeguarding Vulnerable Adults

(HSE, 2014, p.49)

Key Factors in Evaluation and Assessment of Risk client’s capacity

their support,

occurrence, immanency and frequency of the event,

severity of the consequences, and number of other events co-occurring

(MacLeod & Stadnyk, 2015, p.46).

Risk Management

Due Diligence in Practice (Duke 2003)

Know the client’s lifestyle and preferences

Follow all reasonable leads

Know all applicable state and local policy and procedures

Take all appropriate action

in the pursuit of clients safety and

well-being

Determine the underlying causes of (injuries) and

self-neglect

Responding best interest for people’s rights and dignityPerson-centred care

Building relationships

Multi-agency work are key shared risk-management and decision making

Prevention in safeguarding is about empowering Arthur to make small changes and it is not about being over protective.

Community health and social care professionals need to be guided by the philosophies, safeguarding policies, protocols and clinical guidelines of their member states and countries.

Effective decision making needs to balance choice, control, self-determination, independence and well-being and requires sensitivity, reflection and careful evaluation of all options.

(White 2014, HSE 2014)

Summary and Conclusion Self-neglect is a serious and complex public health issue, and ageing demographics will potentially increase the risk of self-neglect’s occurrence

Self-neglect accounts for 19-21% of reports received by Senior Case Workers Elder Abuse Services, HSE

Self-neglect is associated with multiple medical comorbidities and increased mortality.

Comprehensive geriatric assessment coupled with capacity assessment is the best practice for case identification and evaluation

Health and social care professionals need to be knowledgeable about legal issues and safeguarding vulnerable people’s policy and procedural frameworks for adults at risk of abuse and self-neglect

Case studies, serious case reviews, staff supervision and education can be used to develop self-neglect practice.

ReferencesDay M.R. (2016) Self-Neglect: A Concept Analysis In Concept Analysis McCarthy G. & Fitzpatrick J. Ed) (in Print) Springer Publications, New York

Day, M.R. & McCarthy, G. (2015) 'A national cross sectional study of community nurses and social workers knowledge of Self-Neglect'. Age and Ageing

Day M.R. (2015) Self-Neglect: Ethical Considerations Annual Nursing Review Chapter 6, Vol 34, 89-107.

Day, MR, Mulcahy, H., Leahy-Warren, P. & Downey, J (2015). Self-Neglect: a case study and implications for clinical practice. British Journal of Community Nursing 20(3), 110, 112-115.

Day, MR; Leahy-Warren, P; McCarthy, G; (2013) 'Perceptions and views of self neglect: A client-centred perspective'. Journal of Elder Abuse & Neglect, 33(2), 145-156.

Day, M.R. McCarthy, G. & Leahy-Warren, P.; (2012) 'Professional Social Workers' Views on Self-Neglect: an exploratory Study'. British Journal of Social Work, 42 (4):725-743.

Day, M.R. (2012) 'Self-Neglect: A Hidden Killer'. The Boolean, 3, 15-18.

Day, M.R. Bantry-White, E. Glavin, P. (2010) 'Protection of vulnerable adults: an interdisciplinary workshop'. Community Practitioner, 83(9), 29-32.

Day M.R. (2010) 'Editorial Self-Neglect: A Challenge and a Dilemma'. Archives Psychiatric Nursing, 24 (2),73-75

Day, M. R. Leahy-Warren, P. ; (2008) 'Self-Neglect 1: Recognizing Features and Risk Factors'. Nursing Times Research, 104 (24), 26-27.

Day, M. R. Leahy-Warren, P. ; (2008) 'Self-Neglect 2: Nursing Assessment and Management'. Nursing Times Research, 104, 25-28.

Day, M. R. Leahy-Warren, P. (2008) 'Guided Learning Portfolio Self-Neglect' Nursing Times 1-7.

ReferencesDepartment of Health (2013) Positive Ageing starts now: The National Positive Ageing Strategy. Dublin, Stationary Office.

Department of Justice, Equality & Law Reform (2013). Assisted Decision-making (Capacity) Bill House of the Oireachtas, Ireland. http://www.oireachtas.ie/documents/bills28/bills/2013/8313/b8313d.pdf

Government Publications (2009). Nursing Home Support Scheme (Assessment of Capacity report Regulations, Stationery office, Dublin.

Health Service Executive. (2014). Open Your Eyes There is no excuse for Elder Abuse Health Service Executive, Dublin

Health Service Executive. (2014) Safeguarding Vulnerable Persons at Risk of Abuse: National Policy and Procedures. HSE, Social Care Division, Dublin.

Working Group on Elder Abuse. (2002) Protecting Our Future Dublin: Stationery Office

National Centre Protection of Older People http://www.ncpop.ie/

O’Dwyer, C. & O’Neil, D. (2008). Developing strategies for the Prevention, Detection and Management of Elder Abuse: The Irish Experience Journal of Elder Abuse and Self Neglect 20(2), 169-180.

Questions?