Sue C. Jacobs, Ph.D. Ledbetter Lemon Counseling Psychology Diversity Professor

1. 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

2. 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

3. 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

4. Psychologists Neurologists Neuropsychologists Pharmacists Social workers Dentists Counselors Psychiatrists Physical Therapist DHS workers Physicians Geriatricians Family Community Caregivers Spiritual/Religious Leaders Nurses 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

5. 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

6. General Principles of the Ethical Principles of Psychologist and Code of Conduct • (2002, including 2010 Amendments): • http://www.apa.org/ethics/code/index.aspx# • Principles are aspirational in nature, not enforceable

7. 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

8. 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 …..

9. 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

10. 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

11. 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

12. 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

13. 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

14. To be multicultural competent must be aware AWARENESS

15. Identities Identities Continued • Gender • Race(s) • Ethnicity/Country of Origin • Religion/Spirituality • Sexual Orientation • SES/Education/job • Language • Health Status/Ability • 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?

16. Values Worldviews • What are your top Five values? • What about money, status? • Wisdom? • The earth? • ETC ??? • 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?

17. 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?

18. AGEISM • DIVERSITY • MARGINALIZATION • STIGMA • EXCESS DISABILITY IMPORTANT TO CONSIDER IN PROVIDING CULTURALLY COMPETENT BEHAVIORAL HEALTH CARE TO OLDER ADULTS

19. 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?

20. Marginalization…the process by which individuals or social groups are overtly or covertly excluded and relegated to a lower social standing Examples?? MARGINALIZATION

21. Stigma…A mark, symbol, or other indication of deficiency, disgrace or infamy that identifies a person as having an “undesirable” condition. Examples??? STIGMA

22. 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

23. 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

24. 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

25. 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

26. A Few Relatives in their 90s,late 80s, 60s, late 50s and younger: What is Old Old?

27. Client may be individuals, their families, friends, other health care providers, DHS workers, their communities, clergy, healers, a treatment team…..

28. 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

29. 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

30. 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?

31. There is much diversity within racial/ethnic groups • Consider that Asian Americans comprise 26-census-defined 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

32. 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

33. 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).

34. 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…

35. 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…

36. 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…

37. 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

38. 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

39. 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

40. WHAT ABOUT AGING AND DIVERSITY IN YOUR WORK SETTING? Tulsa?? Oklahoma??What about your biases/assumptions?

41. 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

42. 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

43. 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

44. 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

45. 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.

46. What are some situations in which you may encounter an issue of confidentiality in practice with older adults? • With Geriatric Patients? Confidentiality

47. 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

48. 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

49. 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

50. Three keys to ethical practice: consent, consultation, and documentation • And, having and routinely following an ethical decision making model How address these issues ethically?