PREFINAL TOPICS

Evidence-Based Ethico-Legal Considerations in the care of

Evidence. Something that furnishes proof or Older Adults
testimony, or something legally submitted to
ascertain the truth of a matter. A. Laws Affecting Senior Citizens/Older
Persons
Evidence-based practice. The systemic
interconnecting of scientifically generated RA 7432
evidence with the tacit knowledge of the expert An Act to Maximize the Contribution of Senior
practitioner to achieve a change in a particular Citizens to Nation Building, Grant Benefits and
practice for the benefit of a well-defined Special Privileges and for Other Purposes
client/patient group. (French, 1999) - Approved on April 23, 1992 under the
administration of President Corazon Aquino
Evidence-Based Practices in Healthcare
Evidence-Based Nursing. A process by which RA 9257 (Expanded Senior Citizens Act of
nurses make clinical decisions using the best 2003)
available research evidence, their clinical An Act Granting Additional Benefits and
expertise, and patient preferences. (Mulhall, Privileges to Senior Citizens, Amending for the
1998) Purpose Republic Act No. 7432
- Approved on February 26, 2004 under the
Evidence-Based Medicine or Practice. The administration of President Gloria
conscientious, explicit, and judicious use of Macapagal-Arroyo
current best evidence in making decisions about
the care of individual patients. (Dr. David B. Laws Affecting Senior Citizens/Older
Sackett, Rosenberg, 1996) Persons

Evidence-Based Practices in Nursing RA 9994 (Expanded Senior Citizens Act of

Evidence-Based Practice is a way of providing 2010)
nursing care that’s guided by the thoughtful
integration of scientific knowledge with nursing An Act Granting Additional Benefits and
expertise. Privileges to Senior Citizens, Amending for the
Purpose Republic Act No. 7432
Why is EBP needed? Approved on February 15, 2010 under the
administration of President Gloria
●​ Ensures clients receive the best Macapagal-Arroyo
possible services
●​ Encourages lifelong learning by keeping C. Laws Affecting Senior Citizens/Older
nursing knowledge current Persons
●​ Supports sound clinical judgment
●​ Improves nursing care and helps save Key Benefits Provided:
lives ●​ 20% Discount and Exemption from
Value-Added Tax (VAT) on applicable
Goal: purchases
●​ Provide reliable evidence to guide ●​ 5% Discount on Utility Bills (electricity
effective nursing care and water)
●​ Resolve clinical issues with informed Conditions:
approaches ●​ Utilities must be registered in the senior
●​ Achieve excellence in care delivery citizen’s name
●​ Reduce variations in nursing care to ●​ Usage must not exceed 100 kWh/month
support efficient decision-making. for electricity and 30 m³ for water
 ●​ check for the therapeutic and ​ toxic
D. Medications of Older Adults effects of medication in the ​ blood.
-​ Normal aging is associated with certain ●​ evaluate the body’s ability to ​
physiological changes that can metabolize medication.
significantly influence drug response. ●​ Evaluate the need for medication ​
-​ Both pharmacokinetics and to treat the condition.
pharmacodynamics play a role in how a Challenges to successful Medication
person will respond to a drug. Regimens for the Older Adult
Medications and Laboratory Values
●​ Demographics ●​ Right Drug
●​ Today, the geriatric population (persons ●​ Right Amount
65) makes up about 13% of the general ●​ Right Route
population. That number is expected to ●​ Right Times
increase to greater than 20% by the ●​ Right Patient.
year 2040. Major Ethical Principles
●​ One national survey of Goal of Ethical Care:
noninstitutionalized persons, published ●​ Avoiding or minimizing harms and
in 2002, found that 40% of adults aged maximizing benefits. The concern and
greater than 65 years used 5 or more focus should be on preserving and
different medications per week and 12% respecting personhood.
used 10 or more different medications. This is done through:
The effect of Aging on drugs ●​ Recognition of wants
How the person responds to the drug. ●​ Collaboration
​ - absorption ●​ Play
​ - distribution ●​ Validating
​ - pharmacodynamics—what the drugs ●​ Facilitation
do when they are in the body. ●​ Giving
Major Ethical Principles
Drug-related problems in the elderly Autonomy. Refers to one's right to control one's
​ - adverse Drug reaction destiny, that is, to exert one's will.
​ - Food drug Interaction -​ The principal issue revolves around
​ - Polypharmacy whether the older adult can assess the
situation and make a rational decision
Drug-related problem in the elderly independently.
​ - Inappropriate prescribing Beneficence
​ - Compliance -​ Refers to the duty to do good for others
Potentially Inappropriate medications for and specifically to avoid harm in the
geriatric patients process.
Nonmaleficence
Laboratory Values -​ Involves doing no harm and avoiding
●​ Laboratory results for older adults may negligence that leads to harm.
differ from those of younger adults; that Justice
is, the reference ranges or “normals” ➔​ Focuses on nondiscrimination and the
may be different. (Leaving the tourniquet duty to treat individuals fairly
on too long) ➔​ Prohibits discrimination based on
●​ Laboratory values and medication irrelevant characteristics
administration go hand in hand. ➔​ Emphasizes fair, non-arbitrary, and
​ - monitor compliance with ​ non-capricious distribution of resources
medication administration.
Fidelity those with life-limiting illnesses who are
-​ Refers to the duty to keep promises. not yet eligible for hospice support.
Definition:
Palliative care refers to the comprehensive
management of the physical, psychological,
social, spiritual, and existential needs of
patients. It is especially suited to the care of
people with incurable, progressive illnesses.

-​ According to a 1997 taskforce, palliative

care has become an area of special
expertise within:
-​ Medicine
-​ Nursing
-​ Social Work
-​ Pharmacy
-​ Chaplaincy
-​ Other disciplines
Goal of Palliative Care
●​ The goal of palliative care is to achieve
the best possible quality of life for
patients and their families. Control of
pain, of other symptoms, and of
psychological, social, and spiritual
problems is paramount.
●​ Bill of Rights of Long-Term Care
Resident
Grievance Redress
-​ The right to voice grievances and have
them remedied.
Health Information and Involvement
-​ The right to information about one’s
health conditions and treatments and to
participate in one’s own care to the
extent possible.
Bill of Rights of Long-Term Care Resident
●​ Healthcare Provider Choice and Privacy
-​ The right to choose one’s own
healthcare providers and to
speak privately with them.
●​ Consent and Refusal
-​ The right to consent to or refuse
all aspects of care and
Palliative Care treatments.
-​ Palliative care evolved from the hospice ●​ Financial Autonomy
movement in the 1960s and 1970s. It -​ The right to manage one’s own
has since become more mainstream as finances if capable or to choose
nurses and physicians embrace its one’s own financial advisor.
philosophy of whole-person care for
 Medical Goals for Care (Ouslander &
●​ Transfer and Discharge Weinberg, 2003)
-​ The right to be transferred or ●​ Maximize the quality of life
discharged only for appropriate ●​ Manage symptoms of acute and chronic
reasons. conditions to prevent complications and
●​ Freedom from Abuse promote health
-​ The right to be free from all ●​ Prevent suffering and treat discomfort
forms of abuse. End-of-Life Care
●​ Freedom from Restraints According to Phillips and Reed (2009),
-​ The right to be free from all end-of-life caregiving is shaped by eight core
forms of restraint to the extent themes. Here are the first four:
compatible with safety. ●​ It is unpredictable.
-​ Each crisis could be the final
Privacy and Confidentiality one—or merely the next in a
The right to privacy and confidentiality continuing series.
concerning one’s person, personal information, ●​ It is intense.
and medical information. -​ The experience is constant and
Dignity and Respect engulfing, marked by an
The right to be treated with dignity, overwhelming sense of
consideration, and respect in keeping with one’s responsibility that often cannot
individuality. be shared.
Visitation and Access ●​ It is complex.
The right to immediate visitation and access at -​ Caregivers must manage both
any time for family, healthcare providers, and intricate treatment plans and
legal advisors. complicated personal
The right to reasonable visitation and access for relationships with the patient
others. and family members.
●​ It is frightening
Goals of Long-Term Care Nursing Facilities: -​ Events such as falls, bleeding,
Medical Goals for Care (Ouslander & behavioral changes, or
Weinberg, 2003): medication reactions can be
●​ Provide continuing care for chronically alarming and distressing for
ill, disabled, and medically frail persons caregivers.
●​ Promote the highest quality of life ●​ It is affirming.
possible for all residents -​ Bonding with the older patient is
Medical Goals for Care (Ouslander & a moving experience.
Weinberg, 2003): -​ It involves dissolving familiar
These goals are shared by all members of the social boundaries.
healthcare team, with nursing contributing Caregivers and older adults share intimacies
uniquely: such as toileting, changing diapers, or catheter
●​ Provide a safe and pleasing care, which would otherwise not be shared.
environment that supports engagement Origin of Advance Directives
and independence ●​ Patient Self-Determination Act (1991)
●​ Ensure that basic physiological, -​ Purpose of the law: To ensure
psychological, social, and spiritual the rights of individuals “to
needs are met accept or refuse medical or
●​ Maintain or improve function surgical treatment”
Healthcare institutions: Must inform ●​ Unlike a living will, it’s a physician’s
individuals about: order that documents treatment
●​ Their right to participate in healthcare preferences
decisions Transportable across care settings
●​ Their right to make advance directives ●​ Helps reduce unwanted treatments and
Purposes of Advance Directives enhances symptom management
- Written instructions to a healthcare provider WHO CAN MAKE DECISIONS IF THE OLDER
before the need for medical treatment ADULT IS NOT CAPABLE?
- Guidance to healthcare professionals on how (Washington State – listed in order of priority)
to proceed ●​ Appointed Guardian or Durable Power
- Provides immunity for healthcare staff of Attorney (DPOA)
directives ●​ Spouse
Purposes of Advance Directives ●​ Adult Children (18+ years)
Living Will ●​ Parents (if still living and capable)
-​ Specifies the care a person wants under ●​ Adult Siblings
certain circumstances (e.g., ●​ If none of the above are available, a
cardiopulmonary resuscitation or CPR) guardian may be appointed
Durable Power of Attorney for HealthCare Spirituality Among Old Persons
-​ Designates a healthcare proxy to make Supporting Spiritual Needs
decisions on a person’s behalf ●​ Supporting patients' spirituality may be
Types of Advance Directive therapeutic and help improve their
The Five Wishes quality of life. Nurses can assist patients
-​ An advance directive program offered by in fulfilling spiritual needs in the
Aging with Dignity that combines legal following ways:
and personal guidance ●​ Identifying needs
POLST (Physician Orders for Life-Sustaining ●​ Being available
Treatment) ●​ Honoring beliefs and practices
-​ Physician-signed orders that outline ●​ Providing opportunities for solitude
specific treatment preferences based on Promoting hope
the individual’s medical condition ●​ Assisting in discovering meaning in
Discussing Values and Treatment Goals challenging situations
-​ This document helps individuals ●​ Arranging for religious needs to be met
articulate care preferences in a holistic ●​ Praying with and for
and personal way. The five key areas Ethical Dilemmas
include: Acts That Could Result in Legal Liability for
-​ The person I want to make Nurses
decisions if I cannot
-​ The kind of medical treatment I
want or don’t want
Discussing Values and Treatment Goals
●​ How comfortable I want to be
●​ How I want people to treat me
●​ What I want my loved ones to know
POLST – Physicians' Orders for
Life-Sustaining Treatment
●​ Originated in Oregon (1991) and
evolved into a national movement
 Sexual abuse:
Non-consensual contact of any kind with an
older person.
Neglect: The refusal or failure to fulfill a
caretaking obligation, including/excluding a
conscious and intentional attempt to inflict
physical or emotional distress on the older
person.

PREVENTION OF ABUSE
• To increase public awareness and
knowledge of the
issue.
• To promote education and training of
professionals and paraprofessionals in
identification, treatment, and prevention.
• To further advocacy on behalf of
abused and neglected
elders.
• To study into the causes,
consequences, prevalence,
treatment and prevention of elder abuse
and neglect.

●​ Invasion of privacy
●​ Violation of a person’s right to be left
●​ alone or to enjoy reasonable
●​ noninterference with his/her life.

ELDER ABUSE AND NEGLECT

Elder abuse can be defined as "a single, or
repeated act, or lack of appropriate action,
occurring within any relationship where
there is an expectation of trust, which causes
harm or distress to an older person."
TYPES
Physical abuse:
●​ pain or injury.
●​ any action that causes physical
Psychological/emotional abuse:
●​ The infliction of mental anguish. E.g.,
ignoring, isolating, shouting
Financial/material abuse:
●​ The illegal or improper exploitation
and/or use of funds or resources.
Measures to help Nurses Make Ethical
Decisions
Nurses should minimize their struggles
in making ethical decisions by using
critical thinking and employing the
following measures:
1.​ Encourage patients’ expressions
of desires
2.​ Identify significant others who
impact and are impacted
3.​ Know thyself
4.​ Read
5.​ Discuss
6.​ Form an ethics committee
7.​ Consult
8.​ Share