Home Health Care : Ethics of Everyday Living

Home Health Care :Ethics of Everyday Living Philip Boyle, PhD Vice President. Mission & Ethics Catholic Health East

What I am going to do today? • Identify unique moral ecology of home care • Ethics of caring • Caring practices not dilemmas • Flourishing even in decline • Propose a method to identify • Suggest guideposts • Identify best practices

The Moral Ecology The clients • Impaired sensory, cognitive, & functional • Limit autonomy • Subtle clotting and vulnerability • More woman, limited means, power differential & vulnerable positions • Stigma: • Age as disability—unable or less than capacitated • Attendance =Less than capacitated • Adult day care = baby sitting

The Moral Ecology The staff—different professional training • Professional boundaries unclear • Less supervision & mentoring in the field • Becoming intimate with the client • Self disclosure, identifying with client, accepting or giving gifts • Coercion— behavioral limits • Provider no longer the “expert”--power

The Moral Ecology Family informal caregivers in home care • Mainly woman • Need family to cooperate • Family feelings about home care • Exhaustion & frustration

The Moral Ecology The setting of home care • Home-- issues about negotiating personal territory • A client’s home is her castle

The Moral Ecology Externalities: law, regulators, dept of aging • Regulations focus on the quality & safety • Regulation often misinterpreted by outside inspectors and breed a more restrictive and severe interpretations of standards to ensure safety

Focus of concern • Caring • Dignity • Flourishing

Ethics of Care • Pull of responsibility, not demand of obligation • Attention to particulars • Focus on who gives care/power differential • Alleviate pain of aloneness, of vulnerability, of fear, of abandonment, of illness, of dying

Case of Mary • Mary, 82-year-old with mild dementia, • Receives daily care, including bathing, dressing, and toileting • Wanda, 27-year-old single mother with three children, ambivalent about her visits • Mary treats Wanda as the child she never had, and occasionally she gives Wanda tokens of appreciation, including chocolates for Wanda’s children, tips, and objects Wanda knows are special to Mary. • Mary is cranky when Wanda is running late because of child care issues. Mary often barks demeaning orders about how she wants things done.

Case of Mary Wanda overhears Mary’s husband, John, making cruel remarks to his wife also observed threatening gestures. • Wanda noted bruises on Mary’s arms and head, supposedly the result of Mary’s fall. • Wanda is suspicious about the explanation for those injuries, and is increasingly worried about Mary’s safety, she is hesitant to speak to anyone at her agency for fear it could jeopardize her relationship with Mary and John and possibly result in Mary being placed in a nursing facility.

Home Care • What is the ethical problem? • Would it be framed differently if told from the perspectives of each party involved?

Home Care • What values are important to preserve?

Home Care • What facts are needed before proceeding Mary?

Home Care • What actions might respect each person involved in caring for Mary?

Home Care • What kind of care plan ought to be developed? • Think of aims that go beyond the immediate need of her confusion

Behavioral Management • What are the limits of behavioral management? • Difference among? • Humane manipulation • Rationale persuasion • Cajoling • Inducements • Threats • Coercion

What amount of harm should warrant action? • Serious harm • Likely to happen • Alternatives have been exhausted • Intervention will stop the harm

The Case of Warren Disabled semi-obese 60 yr-old with drinking problem Rural setting Criminal history Poor hygiene-refuses some bathing Dysfunctional marital relationship LSW discovers he has a gun “for protection”

The Case of Ms. T Living alone in apartment with 60 stuffed animals and infestation Fire risk Nearly unable for self care LSW presses for extermination and animal removal

Home care • One moral problem: eliciting family care giving and protecting client • Each professional has different perceptions and thresholds of what we count as abuse/neglect. • Families need to be reminded that there is an advocate-you • Abuse needs to be at least reported internally and discussed • State regulations of what counts as abuse and what is reportable needs to be reviewed frequently

Guidelines for Caring Practices • Greet with surname • Introduce your self with a story • Create a sense of equality • Put yourself in their position • Honor privacy • Create opportunity to find out what actions they value • Understand client’s habits • Talk normally

Guidelines for Caring Practices • Discover that they want you to let others know • Promote adult choices • Learn about past & hopes • Be aware of invasive elements of care • What supports client’s self-worth • What is you way of understanding a problem?

Conclusions • Ethics of everyday living • Attention to particularities • Focus: caring, listening, respecting… • Need separate mechanisms—not acute care ethics committees

Home Health Care : Ethics of Everyday Living