WHAT ARE SPECIAL ETHICAL ISSUES IN DELIVERING PSYCHOLOGICAL SERVICES TO OLDER ADULTS?
American Psychological Association
Table of Contents
Why Practitioners Need Information
Working with older adults may present special challenges to the psychologist.
This is because older adults receive care from overlapping and not always
well-integrated health systems. For some adults with chronic illness, both
family members and paid caregivers are involved. In some settings (e.g.,
nursing homes, adult homes, board and care facilities), older adults both
live and receive care in the same facility. With late life also comes increasing
risk of severe physical debilitation and death. Because of these factors,
there are particular ethical issues pertaining to confidentiality and end-of-life
decisionmaking for professionals working with older adults.
- APA's Ethical Principles of Psychologists and Code of Conduct provides a framework for understanding central issues on the ethical treatment of older and younger clients. With older adults, however, issues arise that require careful evaluation and application of those principles.
- It is important to note that unless declared incompetent, the older adult has a right to make decisions to initiate, withdraw, or terminate treatment. They have the right to personal autonomy and to refuse medications, surgery, and research participation.
- In community settings adults, children, spouses, and other caregivers are frequently in contact with mental health professionals. To assure confidentiality, written permission should be obtained from older persons to communicate information regarding their status to relatives or to health care professionals.
- For older persons with dementia, or other forms of significant cognitive impairment, confidentiality issues can become complex because questions may arise about the cognitively impaired older person's ability to give truly informed consent to release information. Competency is a legal judgment, rules for which vary from state to state. However, if the older person is legally judged incompetent, then the appointed guardian is responsible for release of information. Some cognitively compromised persons have signed a document that grants permission to another individual, usually a spouse or adult child, to manage their affairs, in which case this is the person responsible for consent. In some cases the as yet legally competent older client may be willing to sign a consent form, yet the psychologist may have serious doubt about their ability to understand what is being requested. In this case, the psychologist must use best judgment guided by the principle that what is done is in the client's best interest.
- In nursing homes and assisted care facilities, some older clients whom the psychologist sees may be distressed over problems with the facility or staff. Some staff may request information from the psychologist to clarify the nature of the older client's concerns and seek solutions to problems. Authorization to disclose information must be provided by the older client or guardian. Even if permission is granted, the psychologist must communicate only that information that is pertinent to the specific issue at hand.
- The Patient Self-Determination Act of 1990 requires Medicaid and Medicare provider organizations to request at patient admission advanced directives from the client regarding termination of care. Another form of directive is the living will. The psychologist working with a severely ill older person may be part of a decisionmaking process that also includes family and medical personnel regarding end of life issues (e.g., whether or not to make extraordinary efforts to prolong the patient's life). In these circumstances, the psychologist's central task is to help patient and family better understand issues and options and help them to make value laden decisions without imposing the psychologist's own views.
