NCOA Module 10: Legal, Ethical, and Protective Concerns in Gerontological Nursing

Core Concepts of Autonomy and Decision-Making

• Autonomy and Rights #1: Autonomy is defined as the personal freedom to direct one’s own life as long as it does not infringe on the rights of others. An autonomous older adult is characterized as someone capable of rational thought and able to recognize the need for problem-solving. A loss of autonomy is synonymous with a loss of independence. Nurses must be familiar with legal and ethical guidelines regarding competency and decision-making capacity.

• Competency: This refers to an individual's ability to fulfill their role and handle their affairs in a responsible manner. In the legal system, all adults are presumed competent to participate in legally binding decisions. They have the right to make health-related decisions unless a court of law declares them incompetent. In cases of incompetence, a judge assigns a designated person either partial or full guardianship/conservatorship.

• Decision-Making Capacity: This is a clinical term representing a measure of an older adult’s ability to make informed, logical decisions regarding health care. It involves the ability to understand, make, and be responsible for the outcomes of health care decisions. It specifically requires:

  • The ability to understand and process information relevant to the decision, including diagnosis, prognosis, and treatment options.
  • The ability to understand risks versus benefits and apply personal values to the situation.
  • The ability to communicate the decision to others.

• Assessment Considerations: Nurses assessing decision-making capacity must:

  • Recognize the influence of differing religious and culturally based beliefs on judgment.
  • Avoid basing determinations on chronologic age or specific diagnoses.
  • Focus on specific situations and evaluate the person's ability to weigh pros and cons and communicate them.
  • Recognize that capacity can fluctuate from day to day or hour to hour due to various conditions.

• Shared Decision Making: This process involves two main components:

  • Health care providers provide evidence-based information regarding likely outcomes, risks, and benefits of interventions.
  • Discussion of the patient's personal goals as expressed by the patient or a surrogate decision maker.

Legal Documents and Advance Directives

• Illinois Advance Directives: Illinois law recognizes four types:

  • Health care power of attorney.
  • Living will.
  • Mental health treatment preference declaration.
  • Practitioner orders for life-sustaining treatment ($POLST$).

• Durable Power of Attorney for Health Care: Also known as a surrogate health care decision maker or health care proxy. This role is to represent the person during incapacity. It must be initiated while the older adult is still competent but takes effect only when they become incapacitated. Nurses should encourage discussions between the patient, providers, and proxies before a crisis occurs.

• Do Not Resuscitate (DNR) Orders: A specific advance directive compelling providers to refrain from CPR if breathing or heartbeat stops. This should not be mistaken for an order to withhold other medical treatments. A preferred term is "Allow a Natural Death."

  • The three codes are: ($1$) full support, ($2$) intermediate support, and ($3$) comfort support.

• Living Wills: These guide care decisions under specific circumstances, typically applying only when a person is terminally ill. They were the first component of right-to-die statutes. A person must be competent to initiate one and can revoke it at any time.

• Physician Orders for Life-Sustaining Treatment (POLST): These are medical directives meant to ensure patient preferences are honored across all health care settings. They address end-of-life questions such as:

  • Will treatment make a difference?
  • Do the burdens of treatment outweigh the benefits?
  • What are the patient's values and goals of care?

Advance Care Planning (ACP)

• Definition and Process: ACP is a process for individuals at any stage of health to plan for future medical decisions based on personal values. Components include:

  • Clarifying preferences and goals before a serious event.
  • Identifying trusted relatives or friends as proxies.
  • Communicating wishes to proxies and discussing values related to outcomes.
  • Documenting these conversations and legal documents in medical records.

• Three Key Steps:

  • Step $1$: Asking patients to designate a surrogate decision maker.
  • Step $2$: Encouraging patients to talk with family/surrogates about what matters most and recording wishes.
  • Step $3$: Documenting wishes in the medical record.

• Five Wishes Resource: A document addressing:

  • Who is designated for care decisions.
  • Desired and undesired medical treatments.
  • Desired level of comfort.
  • How the person wants to be treated.
  • What the person wants loved ones to know.

Ethical Principles and Nursing Practice

• Guiding Principles:

  • Autonomy: The right of individuals to make their own choices regarding their lives and bodies.
  • Beneficence: Acting in the best interest of others to promote good and well-being.
  • Nonmaleficence: The ethical obligation to not inflict harm intentionally and to minimize potential risks.
  • Justice: Fairness and equality in distributing the benefits and burdens of care.

• Common Ethical Dilemmas:

  • Life-sustaining measures.
  • Physical vs. Chemical Restraints: Physical restraints are any methods or equipment that immobilizes or reduces head, body, or limb movement. The goal is to limit or eliminate these restrictive devices via institutional policy, education, and alternative interventions.
  • Quality of care and professional abuse.
  • Artificial Nutrition and Hydration: Bypassing the GI tract to deliver nutrition. Concerns arise when applied to patients with advanced cognitive impairment, as it often does not improve survival.

• Long-Term Care (LTC) Specifics:

  • The Omnibus Budget Reconciliation Act ($OBRA$) requires residents to be at their highest practicable level of physical, mental, and psychosocial well-being.
  • Staff must perform a comprehensive interdisciplinary assessment within $14\,\text{days}$ of admission.
  • The Nursing Home Residents’ Bill of Rights balances resident rights with institutional needs.

Elder Abuse and Neglect

• Definitions: Elder abuse is defined as intentional actions causing harm or serious risk—whether intended or not—by a caregiver or person in a trust relationship. It also includes the failure to satisfy basic needs. The three categories are:

  • Domestic elder abuse.
  • Institutional elder abuse.
  • Self-neglect or self-abuse.

• Seven Major Types:

  • $1.$ Physical abuse.
  • $2.$ Sexual abuse.
  • $3.$ Emotional or psychological abuse.
  • $4.$ Neglect.
  • $5.$ Abandonment.
  • $6.$ Financial/material exploitation.
  • $7.$ Self-neglect.

• Risk Factors:

  • Social isolation and reduced contact with the outside world.
  • Reluctance of the older adult to admit abuse.
  • Vulnerability caused by dementia, depression, and mental illness.
  • Caregiver risks: Life stresses, pathologic characteristics, personality, insufficient resources, and lack of understanding of the patient's condition.

• Institutional Risk Factors:

  • Lack of abuse prevention policies.
  • Insufficient staff screening and education.
  • Staff shortages and high turnover.

Nursing Assessment and Interventions for Abuse

• Detection: Abuse is often detected via suspicion rather than formal assessment. Assessment begins with suspicions, and home visits are essential. Fears, secrecy, and resistance from the patient or perpetrator can make assessment difficult.

• Physical Assessment Clues:

  • Poor wound healing, burns (stove, cigarette, or hot water).
  • Bruises, swelling, or repeated falls.
  • Pressure ulcers and skin indicators.
  • Infections, poor nutrition, and dehydration.

• Psychosocial and Functional Assessment:

  • Evaluating the ability to perform ADLs safely.
  • Assessing the home environment for basic needs and ability to get help.
  • Checking medication administration (e.g., withholding therapeutic meds).
  • Determining the older adult's capacity for reasonable judgment.

• Nursing Interventions:

  • Institutional: Teaching caregivers, discharge planning, and addressing caregiver stress.
  • Community: Teaching, supervising home health aides, and providing direct care.
  • Interdisciplinary: Participating in elder abuse teams and facilitating referrals for medical equipment or support services.

Legal and Ethical Responsibilities

• Mandated Reporting: Nurses are identified as mandatory reporters in adult abuse laws. This does not require proof of abuse, merely a suspicion based on signs of violence or conditions of neglect. In Illinois, RNs must complete Mandated Reporter Training when renewing their license.

• Adult Protective Services (APS): These agencies provide protection to abused persons. There are no federal guidelines, so services vary across the $50\,\text{states}$; nurses play essential roles in implementing these laws.

• Legal Roles for Nurses:

  • Assessing: Taking a holistic approach.
  • Consulting: Regarding medications, nutrition, and disease signs.
  • Testifying: Providing evidence through direct observation or expert opinion.
  • Communicating: This remains the most vital role in resolving legal and ethical issues.

Case Study Discussion

• The Scenario: A patient has a daughter who is the legal Medical Power of Attorney ($mPOA$). The nurse must decide whether to advocate for the patient (Option $1$) or follow the law and the $mPOA$'s wishes (Option $2$).

• Reality of the Outome: The nurse followed the daughter's (the legal $mPOA$) wishes. The daughter signed a medical refusal form; the patient was extubated, and blood pressure medications were stopped. Because there were no proper orders for comfort medications, the patient suffered throughout the night until a physician arrived in the morning. This highlights the importance of self-reflection and proactive planning for medication orders in end-of-life transitions.