Ethical Considerations in Clinical
Practice with Older Adults and Geriatric
Patients
Friday, March 15, 2012
Northeastern Psychology Internship Program CEU
Workshop, Tulsa, Oklahoma
Sue C. Jacobs, Ph.D.
Ledbetter Lemon Counseling Psychology
Diversity Professor
School Of Applied Health & Educational
Psychology; College Of Education;
Oklahoma State University

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
Today’s Objectives

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
Presentation Outline
Psychologists
Neurologists
Neuropsychologists
Pharmacists
Social workers Dentists
Counselors
Psychiatrists
Physical Therapist
Physicians Geriatricians Family Community
Spiritual/Religious Leaders
Nurses
DHS workers
Caregivers
Other Allied Health Providers
Health Systems: Hospitals, Adult Day Centers, Home
Care, Nursing Homes, Community Centers
Educational Systems
Hospice providers
Differing Professional ethics codes
Have Similar Aspirational
Principles

Beneficence and Nonmaleficence

Fidelity and Responsibility

Integrity

Justice

Respect for People's Rights and Dignity
General Principles of the Ethics Code of
American Psychological Association
General Principles of the Ethical Principles
of Psychologist and Code of Conduct
 (2002, including 2010 Amendments):


http://www.apa.org/ethics/code/index.as
px#

Principles are aspirational in nature, not
enforceable

Nonmaleficence (Do no harm/minimize
harm)

Beneficence (do good)
However, the Nonmaleficence trumps any
desire to be helpful or “do good”
Principles to Guide your practice
and Ethical Decision Making

Fidelity and Responsibilty: Whom entrusts us to provide
ethical care and to whom are we responsible?
Clients/Patients may be individuals, their families,
friends, other health care providers, their communities,
clergy, healers …..

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)
Integrity
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.
Give equal access, be aware of own
biases, and limits of competence
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.

Especially important with increasingly
diverse older clients/geriatric patients
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
 KNOWLEDGE
 AWARENESS
 SKILLS

What Competencies are needed for ethical
practice with older clients? Geriatric
patients? Others in their lives,
communities, and systems of care?
Competency

To be multicultural competent must be
aware
AWARENESS
Identities
Gender
 Race(s)
 Ethnicity/Country of
Origin
 Religion/Spirituality
 Sexual Orientation
 SES/Education/job
 Language
 Health Status/Ability

Identities Continued
Rural/Urban
 Age
 Living situation
 Who do you consider
family
 Cohort history…
 In relationship to
others or ???

What are your identities? Your
clients’/patients’ identities?
Values

What are your top
Five values?
What about money,
status?
 Wisdom?
 The earth?
 ETC ???

Worldviews
Views on life and death
 Views on older adults
and aging
 Views on community/
family vs individuals in
decision making
 Views on roles
 ETC.???

What are your 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?
What are your clients’/patients’
families values and world views?
 AGEISM
 DIVERSITY
 MARGINALIZATION
 STIGMA
 EXCESS
DISABILITY
IMPORTANT TO CONSIDER IN PROVIDING
CULTURALLY COMPETENT BEHAVIORAL
HEALTH CARE TO OLDER ADULTS
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.

AGEISM: What are your views?
Marginalization…the process by
which individuals or social
groups are overtly or covertly
excluded and relegated to a
lower social standing
Examples??
MARGINALIZATION
Stigma…A mark, symbol, or
other indication of deficiency,
disgrace or infamy that
identifies a person as having an
“undesirable” condition.
Examples???
STIGMA
 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.
EXCESS DISABILITY

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.
Standard 2 of APA Ethics Code

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?
KNOWLEDGE
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…..
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
Some Key points: Demographic
diversity in older adults and aging
U.S. population
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.
Context of Ethical Clinical Practice:
Aging Tsunami

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).
Who are we talking about in terms
of diverse older adults?
 There
is much diversity within
racial/ethnic groups
◦ Consider that Asian Americans comprise 26-censusdefined 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 ponder
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.”
More demographics to consider: Gender

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).
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
Income…

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…
 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
Religious diversity issues…

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 often at
high risk for 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.
Culturally diverse older adults also
often at high risk for mental illness
 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
Health Literacy
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 Adults






Clinical competence to work with older
adults
Multicultural competency
Multiple Relationships
Confidentiality
Issues of Consent
Relationships with other professionals
Additional ethical (and legal)
issues/dilemmas In providing
clinical services to older adults





Assessing older adult’s physical and cognitive
competence and ability to make decisions
Issues of older adults’ physical and
psychological safety
Issues of abuse and neglect
High 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
Patients
Same as with older adults
 Clinical Competence in context of
“Generalist” care and multidisciplinary
team/interdisciplinary team care


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?
Multiple Relationships
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 the
multiple relationship could reasonably be expected to impair the
psychologist’s objectivity, competence, or effectiveness in performing
his or her functions as a psychologist, or otherwise risks exploitation or
harm to the person with whom the professional relationship exists.
Multiple relationships that would not reasonably be expected to cause
impairment 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.

What are some situations in which you
may encounter an issue of confidentiality
in practice with older adults?

With Geriatric Patients?
Confidentiality
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 is not just a piece of paper.
Necessity for mutual discussion of what
consent is for and in what situations
 Question 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.?


Consent
Cooperation with other professionals
 Disclosures
 Conflicts 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
Relationships with other
professionals

Three keys to ethical practice: consent,
consultation, and documentation

And, having and routinely following an
ethical decision making model
How address these issues
ethically?
Issues to consider:

How do you normally make tough ethical
decisions?

Do you have a decision making model you
follow?
What Can You do?
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!
Importance of thinking about
the way you make ethical
decisions
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

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
Prevention and positive practice
approach to ethical decision
making
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?
 Knowledge
Aging trends and increasing diversity
Attitudes towards mental health and health care
Resources 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
Brief review and reflection
Questions,
Comments,
Discussion
Resources
THANK YOU!
Sue C. Jacobs, PhD
School of Applied Health and Educational Psychology
425 Willard Oklahoma State University
Stillwater, OK 74078-4024
405-744-9895 Fax 405-744-6756
[email protected]
 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.as
px
I
have noted the web link to many resources
change frequently…Google and Psychingo and
Ageline are helpful in this regard
Resources






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%20Cod
e%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/medicalethics200
1 42001.cfm
Selected References





For other mental health ethics codes, a good
source is:
http://www.centerforethicalpractice.org
Other references
American 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, & WeidenbacherHoper 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

More References
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