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RESOURCE AND TRAINING KIT FOR SERVICE PROVIDERS:
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Category of Abuse and Neglect |
Indicators6 |
|
Physical abuse |
- unexplained injuries such as bruises, bums or swellings - injury for which the explanation does not fit the evidence - delay in seeking treatment - injury to scalp (evidence of hair pulling) - symmetrical grip marks (evidence of shaking) |
|
Psychological or emotional abuse |
- fear - withdrawal - low self-esteem - extreme passivity - appears nervous around the caregiver/family member |
|
Financial abuse or exploitation |
-unexplained discrepancy between known income and standard of living - an older adult has signed a document (e.g., will, property deed) without full understanding - possessions disappearing - if you work in a financial institution: an older adult is surprised by an overdrawn or lower-than -expected bank balance; unusual transactions conducted on behalf of an older person |
|
Sexual abuse |
- pain, bruises or bleeding in genital area |
|
Medication abuse |
- reduced mental or physical activity - depression - reduced/absent therapeutic response |
|
Denial of civil/human rights |
- difficulty visiting, calling or otherwise contacting an older adult - older adult makes excuses for social isolation |
|
Neglect/self-neglect |
- malnourished, dehydrated - missing dentures, glasses, hearing aid - unattended for long periods or tied to bed/chair - unkempt appearance, dirty or inappropriate clothing -untreated medical problems |
Make more than one visit in order to adequately address all the questions for a full assessment. Information is needed on the older adult's sense of his or her own health and happiness; on the caregiver, if there is one, and his or her needs and reactions; and on the extended family and social network. The older person may need support and comfort from many people to stop abuse or neglect. On the other hand, this information may be important because it could be a person outside of the home who is abusing or neglecting the older person.
In instances when an older adult cannot speak freely in the home or when access to the older adult is denied, use the phone to contact the older adult when the abuser is not present. Arrange an interview somewhere else in the community, such as at the family doctor's office.
Assessments in institutions are carried out by visiting the older adult and observing the situation. Records can be reviewed, staff and family interviewed. Contact the institution management to enlist cooperation.
Conduct assessment interviews with sensitivity to the fact that you are a guest of the older adult. While certain information is needed to make an assessment, at no time alarm the older adult by questioning in a threatening way.
Approach a caregiver who may be abusive or neglectful with genuine concern about the heavy toll that caregiving places on an individual, but with the understanding that abuse and neglect will not be tolerated. Abuse and neglect is seldom a clear-cut situation of good versus bad. Give the caregiver information on community resources such as respite care and employment counselling, or advice on stress management and finances.
Provide information about programs to the older adult and offer to make any necessary arrangements. This may include day programs, foot care clinics, transportation or homemaker services. If the older adult lives alone, a friendly visitor and help with banking or shopping can be offered.
The focus of the assessment is to improve the functioning of the older adult - using the home, the family, the social network and the wider community. The goal is to make it possible for the older adult to be safe and healthy. Make every effort to resolve the conflict. The removal of the older adult from his or her home is a last resort, so it may become necessary to remove the abuser. Help people deal with the emotions this may cause.
Recognize that every adult is an individual with the right to make decisions, as long as he or she does not cause harm to others. It may be easy to adopt the role of "rescuer" in cases of perceived abuse or neglect, but it often leads to choices that are wrong for the older adult.
Sensitivity to racial, cultural and religious differences make assessments more effective. Attempt to involve someone familiar with these differences when doing an assessment or outlining options available to the older adult.
Display Summary 7 during presentation.
Participants can divide into groups (multi-disciplinary if possible) and make up case studies. They can then discuss ways to gain access to a home where abuse or neglect is suspected, assess needs and involve community resource groups. Bring the study groups together to share case studies and ideas. Have them draw up a community resource list.
Presentation
Before beginning to gather information, determine if any previous interventions or suggestions of abuse or neglect exist. Respect confidentiality and privacy, and check information on a "need-to-know basis." Gather information by speaking directly to the older adult. Maintain full documentation on cases and note past interventions, including the type of action taken and the success in resolving the situation.
A full needs assessment will include:
These observations, while subjective, may indicate health problems or nutritional needs.
Include questions about the older person's own perceptions of:
In situations where the older adult is from another cultural or linguistic background, document the effect of the different background on the gathering of information. This documentation, if systematically included in case reports, can substantiate the need for interpreters or advocates from ethno-cultural communities.
Over the past 10 years a number of assessment tools have been developed to help service providers.
The most important measure of any assessment is the degree to which it addresses individual needs in each case. Assessment will only be effective if it aids the older adult in identifying his or her needs and the available services. A word of caution: assessment tools may not give enough weight to the particular personalities and circumstances of the older adult and family members. This can have negative effects including the refusal of the older adult to accept help. It is important to develop an assessment approach that involves the willing participation of those concerned.
The complexity of the issues and factors surrounding abuse and neglect requires the expertise of an inter-disciplinary team. Nurses and other health care practitioners are trained to use medical criteria to assess cases; lawyers and the police are more aware of the legal aspects; psychiatrists can assess mental health dimensions of a situation; and social workers have a broader social approach to problem solving. Each of these disciplines can contribute to a comprehensive understanding of situations of abuse or neglect.
When a full range of disciplines cannot be represented on a team, it is still essential that all key areas of concern be addressed by the team. This team approach does not preclude the use of assessment tools, but may address some of the limitations inherent in such tools.
The community approach can be expanded to include professionals in the community who have regular contact with older adults. For example, a banker may have a chat with a client whose financial transactions are out of character. Information on alternative banking arrangements to protect the person can be offered. A dentist can keep the office stocked with information about community resources, and can show a personal interest in patients. An office supervisor who knows that an employee is caring for a parent can be flexible about work
hours and if available, can arrange for a counsellor from an Employee Assistance Program (EAP) to offer practical advice on resources.
Hand out Resources 8, "Interview Questions;" and Resource 9, "Adult Protection Service Assessment Form."
Introduce Case Studies 7, 8, and 9, "Community Responses to Abuse and Neglect -A, B & C."
Presentation
Each of us has an individual value system, and it is often difficult to recognize the effect these beliefs have on our professional and personal relationships. It is even difficult to admit to ourselves that we have certain biases.
Like other people, service providers dealing with the abuse and neglect of older adults can let personal values affect their responses to others. Past exposure to violence, for example, may make some service providers more tolerant of certain types of mistreatment or more vengeful toward certain abusers.10 A person's value system does affect decision making and service providers need to recognize and reconcile their values with their responsibilities. This may require a change in deep-seated attitudes.
In the past, service providers were often solely responsible for dealing with problems of abuse and neglect. The wider community was often unaware of the extent of the violence or reluctant to accept the unpleasant facts. Lawyers, bankers, medical or dental professionals and business people, dealing regularly with older adults who may have been abused or neglected, typically offered little support to service providers trying to help them. Because these professionals and business people only dealt with older adults as clients, they felt no responsibility to probe deeper.
For service providers with little or no support systems, this isolation meant that they had to draw on inner resources to find energy and motivation, and rely on training which often did not include much education on the aging process or on abuse and neglect issues. Service providers had to combat negative reactions of others, while fighting their own feelings of denial and disbelief, fear, anger and impatience.
In recent years, a growing awareness in the community about the extent of abuse and neglect has occurred. More professionals police, bankers, doctors, dentists, and lawyers who have been working in fields dealing with other forms of family violence - have taken supportive roles, offering their expertise and commitment to those on the front line.
Canadians have come to realize that this is a problem that can only be solved by involving the whole community. Governments have taken an active role in trying to ensure protection through legislation, and many community resource groups have established services to help older adults live full and independent lives. The need still exists for more public education programs both within professional groups and in society as a whole.
Before examining "Barriers" in the next section, encourage participants to create lists of possible barriers to proper identification and response.
Presentation
Attitudes and beliefs affect the response to abuse and neglect of older adults. Some of the more common attitudes and beliefs about abuse and neglect are listed below.
Attitudes are feelings or emotions about a fact or state.12 Attitudes towards abuse and neglect of older adults include
Beliefs are opinions or convictions about some reality.13 Some false beliefs about abuse and neglect of older adults include
Additional barriers to identification and response for staff in an institutional setting include
Display Summary 8 during presentation.
Compare lists of barriers to identification and response.
Presentation
Older adults who are abused or neglected, are often reluctant to disclose mistreatment. Barriers to disclosure can include:14
An understanding of the older person's perspective may help reduce barriers.
Display Summary 9 during presentation.
Lead a discussion on the barriers to disclosure for older adults.
1. Canada, Mental Health Division, Community Awareness, p. 10.
2. Canada, Mental Health Division, Community Awareness, p. 17,
3. Canada, Task Force on Mental Health Issues, p. 15-16.
4. Podnieks, p. 20.
5. Canada, Mental Health Division, Community Awareness, p. 10.
6. British Columbia InterMinistry Committee, p. xxiii.
7. Ranjy Basu, Elder Abuse: A Practical Handbookfor Service Providers (Toronto: Ontario Association of Professional Social Workers, April 1992), p. 17-29.
8. Terry Fulmer & Terrence O'Malley, Inadequate Care of the Elderly (New York: Springer Publishing Company, 1987), Appendix B, p. 161-173.
9. Fulmer & O'Malley, p. 32-49.
10. Deborah Bookin & Ruth Dunkle, "Elder Abuse: Issues for the Practitioners," Social Casework: The Journal of Contemporary Social Work, Vol. 66, No. I (January 1985), p. 3-12.
11. Henry Bosley Woolf (ed), Webster's New Collegiate Dictionary (Toronto: Thomas Allen & Son Ltd., 1980), p. 72.
12. Woolf, P. 100.
13. Judith Wahl & Sheila Purdy, Elder Abuse: The Hidden Crime (Toronto: Advocacy Centre for the Elderly & Community Legal Education Ontario, 1991), p. 8-9.
Module I: Ethics of Intervention
Module II: Issues Concerning Intervention
Module III: Mental Competency
Module IV: Process of Intervention
Module V: Legislation
Presentation
Everyone has the right to life, liberty and security of person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.'
The basic rights granted under the Canadian Charter of Rights and Freedoms create dilemmas in the intervention stage of dealing with cases where abuse, neglect or self-neglect have been identified and confirmed. Intervention plans are devised to protect the older adult from further harm, but he or she has the right to refuse assistance unless:
In most cases, intervention must be voluntarily agreed upon. Therefore, for ethical as well as practical reasons, action plans should be the least intrusive and least restrictive, while best addressing individual situations. In other words, action plans should involve the older adult as much as possible and disrupt the life of the older adult as little as Possible. Plans should also allow the older adult to make his or her own decisions as much as possible.
There are ethical considerations when intervening in abuse and neglect cases.
In essence, ethics is a form of reasoning. It is a reflective process that attempts to answer the basic question: "What should I Do in This situation, All things considered?" It is important to emphasize that ethics involves reasoning not just for its own sake, as we might theorize, say, about the origin of the Universe. The domain of ethics is the domain of action; moreover, action that is concerned directly with our own life or other people's lives.2
Display Summary 10 during presentation.
The following are three examples of ethical dilemmas in interventions:
Restraints are commonly used in institutions to prevent falls, stop wandering or aggressive behaviour, and to protect medical devices, such as catheters. Restraints include bedrails, cloth or leather straps, and 'geri-chairs' (wheelchairs with fixtures to keep the person from rising).
The use of restraints raises ethical questions.
Included in a discussion of the ethical dimensions involving the use of restraint are considerations for basic human rights, quality of life issues, the right to fall with the potential for injury in exchange for freedom, and issues of decision making. Dignity, independence, and a sense of control become even more important when an older individual is institutionalized and faced with increasing physical and emotional limitations and personal losses ... The principle of autonomy speaks to the right of competent persons to make decisions about their own health care. However, most older patients who are restrained are confused and suffering from some degree of dementia. This poses the dilemma of making the decision in the best interests of the patient, whether to restrain or not to restrains
In some cases one form of restraint is substituted for another when objections are raised. Too often, physical restraints are replaced by drugs to make the older adult more manageable. These chemical restraints limit the ability of the older adult to respond to his or her environment, causing a sense of helplessness and a fear of loss of control over his or her life.
Effective alternatives to restraints exist that are more respectful of older adults' dignity. These include:
Introduce Case Study 10, "Ethical Issues and Restraints."
Introduce Case Study II, "Ethical Issues and Assessments." The case of Samuel illustrates: systemic abuse.
This case also raises the issue of our responsibility as a society. Have participants identify ways in which they can have a positive input into the assessment process.
Introduce Case Study 12, "Ethical Issues and Borderline Situations of Abuse and Neglect."
This scenario may not fit into the usual perceptions of abuse and neglect and is illustrative of why it is so difficult for researchers to agree on standard definitions. Many situations are not covered by blanket definitions.
Is this a case of abuse or neglect?
How can this type of situation be prevented in the future?
Presentation
Standards of action vary among the different professions or businesses that interact regularly with older adults. Lawyers, police, medical and dental practitioners, bankers, landlords, religious leaders, service providers, and business people all have different points of entry into the daily lives of older adults. Their dealings are conducted in distinct ways, using a range of contractual, regulatory or communication tools.
The term "intervention". . . is intended in the broadest sense. It refers to various formal methods of treatment, education, social policy and research. Intervention can refer as well to the informal decisions family members make about each other's lives.5
Display Summary II during presentation.
Use the "Protocol for Home Care and Support Workers" (Resource 10), to encourage participants to identify principles and suggest others that are not included in the model.
The following ethical principles can serve as a guide for a community's response to abused and neglected persons. They can help formulate thoughts on approaches and interventions.
1. As with all adults, older persons have the right to:
2. Every situation involving suspected abuse and neglect must be assessed individually to determine what the older person wants and the degree of intrusion warranted. Situations will vary in degree of risk for the adult person.
3. In a suspected case of abuse or neglect, an intervention:
4. Assault, theft, uttering threats, fraud and neglect are crimes. The police should be called to deal with complaints of instances of alleged criminality.
[Adapted with permission from the British Columbia InterMinistry Committee on Elder Abuse, and Continuing Care Division, Ministry of Health, and Ministry Responsible for Seniors. (February 1992). Principles, Procedures, and Protocols for Elder Abuse, pp. 3-4]
Introduce each of the issues (confidentiality, lifestyle and culture, and individual autonomy) and ask participants about different approaches professionals can take. These are complex issues, often raising as many questions as they answer. Ask participants for opinions on the best possible solutions in each instance. Emphasize that each solution may not be the ideal one but, given the circumstances, it is the one which will be the least intrusive and least restrictive.
Presentation
Maintaining confidentiality is the basis for interactions between service providers and their clients. Various professions have incorporated this principle into their codes of conduct. Confidentiality means safeguarding information about the individual obtained in interactions, and not revealing this information to others except under certain circumstances, for the purpose of helping the person.6 Service providers can encounter situations where maintaining confidentiality can difficult.
Discuss professional confidentiality in the following scenarios.
Discussion questions:
Presentation
Another issue affecting interventions is the judgements we make about a person's lifestyle. For example, self-neglect may be influenced by financial problems, ignorance or incompetency, or some older adults may be making a conscious choice to live in a manner which may be considered risky. Care must be taken before intruding in the lives of older adults.
Interventions are also affected by cultural and language differences. Communication can sometimes be misleading, even in the absence of language differences. The following example, shows how cultural values can come into play within the Japanese-Canadian community:
... apparently affirmative answers may in fact indicate negative responses; to inquire directly concerning meaning would be both clumsy and rude. Furthermore, the perceived status of the interviewer as well as generation and education of the respondent will be factors in the application of cultural values which make detailed explanations inappropriate and insulting because of implications of lack of intelligence. 7
Introduce the issue of the right of older adults to be at risk for discussion. This issue is central to the controversy about whether or not self-neglect is mistreatment.
Presentation
Service providers may face a conflict between professional values and legal norms when dealing with older adults at risk who refuse intervention. Our primary goal should be to protect the dignity and rights of the individual.
Older adults who are mentally competent have the fight to refuse medical interventions including treatment required to sustain life. Medical technology now makes it possible to prolong patients' lives with transplants, chemotherapy, resuscitation and intensive care. However, some treatments involve considerable discomfort, loss of mobility or other side effects. Some measures merely prolong the process of dying, without improving functioning.
A patient may prefer palliative care, even though this may shorten his or her life. The older adult has the right to be informed of the options and to make his or her own decisions. Neither the doctor nor the family should apply pressure on the patient. However, there may be situations where a doctor has ethical reservations about the end-of-life choices made by the patient.
Lead a discussion on individual autonomy.
Presentation
We have discussed the protection of the autonomy of older adults and looked at ways of ensuring that all intervention plans take into account the rights of the individual to make his or her own decisions and to live at risk if that is the individual's choice. However, sometimes older adults are not mentally competent to manage their own affairs.
In this context, competency can be defined as an older person's ... ability to understand the situation he or she is in and the decisions he or she has to make; not simply in terms of the immediate circumstances, but in terms of the risks of continuing in the situation, as well as the alternatives that are available. As with all adults, older people are considered capable of making decisions and managing their own affairs until it has been proven otherwise.8
Competency is not a single ability, but rather a series of abilities, some of which a person may or may not have. "People do not have competency, they have competencies."9 For example, a person may not be capable of making financial decisions, but may be competent to consent to medical treatment. This is called task-specific competency.
No standardized approach to assessment exists across Canada, nor is there any "universally accepted clinical test of competency for any of the abilities recognized as socially significant in health care and law."10
The concepts of "mental incompetency, "mental incapacity" and "mental infirmity" are vague and stigmatizing. They defy effective, objective measurement There are no satisfactory, standard definitions - no consensus regarding the measurement of these conditions. The law assumes they can be identified accurately by medical practitioners but the legislation does not require that a particular assessment technique be used. Some medical practitioners may assess an adult by using a formal and standardized mental status test, while others may prefer different and even less reliable techniques such as personal impressions and hearsay. Practitioners may simply assume that a diagnosis of mental disorder is sufficient "evidence" of incompetency."
Because competency is a series of abilities, it needs to be assessed in relation to specific tasks people wish to perform or consent to. This is sometimes called 'functional assessment.'12 A functional competency assessment can be a practical means of integrating personal freedom and care, because it can:
[Adapted with permission from Michel Silberfeld and Arthur Fish, When the Mind Fails: A Guide to Dealing With Incompetency (Toronto: University of Toronto Press, 1994), pp. 71-74.]
An informal competency assessment can help decide if a formal competency assessment is needed or not. The following rules may help guide decisions:
Situations when formal assessments are justifiable are:
Situations when formal assessments are not justifiable are:
When to seek a formal competency assessment:
The following factors suggest that a person is at significant risk of harm:
For competency assessments, the older adult may be more comfortable at home, but the impact of a team visit may be too intrusive. In these assessments, family and community support systems around the older adult can be taken into account, as well as the older adults' coping mechanisms in performing daily tasks.
Display Summary 12 during presentation.
Presentation
The most vital point about competency legislation is that common law assumes that the individual is competent until proven otherwise.
Competency rulings pave the way for the system to protect older adults who are incapable of managing their affairs, by appointing a trusted person or agency to make certain decisions on the older adult's behalf. This legal safeguard can protect older adults who are vulnerable to abuse or neglect. On the other hand, if the threat of assessment for incompetency is used as a means of applying pressure on a person who has refused intervention, as is his or her right, this is clearly a violation of civil/human rights.
Below is a synopsis of competency legislation in each Atlantic province.
Newfoundland: Mentally Disabled Persons' Estates Act, R.S.N., 1990, c. M-10 A "mentally incompetent" person means a person 1) in whom there is such a condition of arrested or incomplete development of the mind, whether arising from inherent causes or induced by disease or injury, or 2) who is suffering from such disorder of the mind that he [she] requires care, supervision and control for the protection of his [her] property, whether or not he [she] has been committed to the hospital under the Mental Health Act, as amended.
If it is proved to the satisfaction of the court or judge that a person through mental infirmity arising from disease, age, habitual drunkenness, the use of drugs or any other cause whatsoever is incapable of managing his [her] affairs the court or judge may so declare without making a declaration of mental incompetence.
New Brunswick: Infirm Persons Act, R.S.N.B., 1973, c. 1-8, ss. 1, 39 A "mentally incompetent" person means a person 1) in whom there is such a condition of arrested or incomplete development of the mind, whether arising from inherent causes or induced by disease or injury, or 2) who is suffering from such disorder of the mind that he [she] requires care, supervision and control for his [her] protection or welfare or for the protection of others or for the protection of his [her] property.
This does not apply to a person not formally declared incompetent. The mental infirmity provisions are meant to be an alternative procedure that avoids declarations of incompetency. It applies to those who are, through mental or physical infirmity arising from disease, age, or other cause, or by reason of habitual drunkenness or the use of drugs, incapable of managing their affairs or providing for their management.
Nova Scotia: Incompetent Persons Act, R.S.N.S., 1989, c. 218, s. 2(b) ... insane person or lunatic means a person, not an infant, incapable from infirmity of mind of managing his [her] own affairs.
Public Trustee Act, R.S.N.S., 1989, c. 379, S. 8(1) The public trustee may be appointed the guardian of the estate (when the person is) by reason of physical disability incapable of attending to and transacting his [her] business affairs. Where the court is satisfied that the person is suffering from such incapacity and is unable to attend to or transact his [her] own affairs or business and by reason thereof his [her] estate is in jeopardy.
Prince Edward Island: Mental Health Act, R.S.P.E.I., 1988, c. M-6. s. 1(m) A person in need of guardianship means a person 1) in whom there is a condition of arrested or incomplete development of mind, whether arising from inherent causes or induced by injury, or 2) who is suffering from such a disorder of the mind that he [she] requires care, supervision and control for his [her] protection or the protection of his property.
Present your current provincial/territorial legislation on competency legislation. This legislation can be obtained from, provincial/territorial departments of health or social services.
Introduce the case history of Mrs., K. (Case. Study] 3). This is an example of an application of incompetency under adult protection legislation and it can help participants understand the implications on the lives of older adults.
Presentation
Dealing with abuse and neglect of older adults can be a complex problem because each case is distinct. The dynamics between the abuser and the abused person, or in the case of self-neglect, the underlying reasons for living at risk, are different in every case. Mistreatment is also rarely limited to one type of abuse or neglect. It is, therefore, necessary to approach each situation individually.
At the same time, it is important to keep in mind that no fixed strategies can apply to all cases. Instead, responses or treatment plans have to be individualized.
Several community resources are available to meet some of the primary needs of the abused or neglected adult. These may include:
The people who provide these services, and those who have daily interactions with older adults, require proper training about abuse and neglect to recognize the signs. They can also play an important role in raising community awareness about the prevalence of this problem.
Health and social service providers may intervene indirectly or directly.
Indirect intervention may include:
Direct intervention of a voluntary nature, where access to the mistreated person is possible, may involve:
Direct intervention can also include educating all those involved about the rights of the individual and the options that are available to end abuse and neglect.
A protocol is a detailed framework of procedures to follow in a given situation. It is a form of support for the front-line service provider because it may:
Protocols for assessment and intervention in cases of abuse or neglect are a necessary aspect of case development. These protocols are useful at every level, and need to be in place for community agencies, professional services, care facilities, social services and legal agencies. To be effective they need to be developed within certain guidelines.
Display Summary 13 during presentation.
Groups could discuss and develop protocols, using the following sample protocols as guides.
Presentation
Service providers who deal with older adults with mental health problems due to brain disease, depression or chronic medical problems, recognize the need for a co-ordinated and informed approach. This starts with the health or social service provider as the front-line primary care provider, working closely with community resources such as homemaker services. Doctors can play a role in liaising with the family and hospital, if there is a need for acute care. Not only are these people the patient's link to the community, they also supply important information and observations on his or her medical and personal history.
Within a hospital setting, a co-ordinated approach to the care of older adults with mental health problems is needed. Discharge planning needs to begin when the older adults is admitted to the hospital, and should involve service providers, family members and community resource groups. This process ensures that the older adult's needs are met once he or she returns to the community.16
Within the hospital, specialists from a range of medical fields can have input into the care of the patient. This is an important aspect of care because mental health problems are often accompanied by medical and social problems. Protocols can ensure a multi-disciplinary approach and at the same time, ensure that a case manager is assigned to co-ordinate patient care.
At all levels of care, ongoing training and public education programs are needed to:
Protocols for daily care regimes in long-term facilities can be designed with built-in intervention procedures. Since many residents suffer from varying degrees of cognitive or physical impairment, treatment plans must consider the implications for the rights of the residents. Protocols can include:
Because treatment plans for older adults with psychiatric disorders often involve dealing with behavioural problems which change as a disease progresses, the attention of the staff may be focused on dealing with the disruptions caused by the behaviour. The potential for staff to violate the rights of the older resident exists if decisions are made for the older resident in order to maintain control over the situation. Standard protocol should include regular updating of treatment plans by care staff, with the assistance of health professionals, to reflect the level of competency and the implications for decision-making in tasks of daily living.
Decisions about personal care take on an added ethical importance if the expressed preference of the resident leads to concern about health and safety (e.g., the resident consistently refuses to eat, will not bathe, wanders dangerously). If the resident is found competent, his/her decision must be respected,- if this leads to an untenable situation, and all reasonable options (e.g., normal persuasion, environmental adaptations and behaviour management approaches) have been explored, discharging the resident may be the only recourse. If, on the other hand, the resident is not competent to give or withhold consent, the LTC [Long term care] facility has the responsibility to seek a valid consent from a substitute decision maker.18
The following section contains some general guidelines on the overall process of follow-up procedures. These can be developed and discussed in workshops with service providers.
Presentation
Maintain detailed documentation of all aspects of the casework, including accurate notes on:
As these records may be needed at a later date for legal interventions, it is important to record date, time and place. Make these notes as soon as possible after any interaction has taken place.
At each new stage of intervention, discuss the case with a supervisor. A supervisor can help:
When a person makes a report about abuse or neglect, reassure the person that he or she cannot be sued for reporting, unless there is malicious intent. At the same time you can give assurance of confidentiality, but inform the person that he or she may have to testify at a later date. Because intervention strategies may include eliciting the help of neighbours or members of the community, especially those who have cared enough to report their concerns, it is important to be as open as possible with them.
If a report must be formally made to another agency, government official or the police for Criminal Code offenses, take the action only with the full knowledge of the supervisor. On the other hand, if unsure about how to proceed in a case, involve other experts such as police, adult protection workers, health professionals and legal experts in an advisory role. A multi-disciplinary approach to intervention is both practical and ethical.
In cases where the need arises, legal intervention may extend to:
Legal interventions have the potential of violating the right of the individual to refuse help. This is especially true if not enough support services are in place for a less intrusive form of intervention.
Introduce the question of allocation of resources. Use the example of adult protection legislation that makes provision for court orders to enter the house of a suspected abused or neglected person. If not enough service providers are on staff to investigate reports in the less intrusive manner this may, become the most commonly used form of investigation,
Introduce the case study of Mrs. Smith from Nova Scotia (Case Study 14). Ask participants .to analyze the use of a restraining order as the intervention procedure.
Presentation
Canadian society is regulated by informal codes and standards of behaviour. As the needs of the older population change, codes and standards are constantly being adjusted and new ways are being found to respond. This usually involves ongoing public awareness programs and community resource development.
Society is also regulated by laws and statutes, at national, provincial/territorial and municipal levels. Often, these laws are slower to respond to changing social conditions.
Canadian law attempts to balance the rights of the individual with the good of the community. Laws are developed by elected officials who are mandated to represent the interests of their constituents. It is the collective responsibility of all citizens to inform legislators when laws need to be changed or created.
Because federal legislation applies to every Canadian citizen, these laws apply to the protection of older adults. As awareness of the issue of abuse and neglect grows, community leaders and people in the legal profession can play an important role in advocating changes in the law to address this issue.
The Canadian Charter of Rights and Freedoms states: "Everyone has the right to life, liberty and security of person and the right not to be deprived thereof except in accordance with the principles of fundamental justice." The Charter overrides all other statutes and is especially important to older adults in cases where they are in danger of losing their rights as individuals competent to make decisions.
Display Summary 14 during presentation.
Ask participants to develop a scenario where the Canadian Charter of Rights and Freedoms could be used to protect the rights of older adults. For example, when an older adult appeals a provincial court decision appointing a guardian to manage his or her estate, he or she may be able to show that the assessment procedure did not take into account all possibilities for the perceived incapacity, e.g., flu, medication or language barrier. Since incompetency guidelines in Canada are generally vague, this case may not be hard to prove.
Presentation
... serves to protect all Canadians from crimes against the person such as assault, manslaughter, murder, and robbery, that is, theft with violence. Crimes against property include arson, vandalism, break and enter, theft, illicit drug dealing and illegal phone calls (obscene or harassing). Civil actions, known as suits, are initiated by the individual, whereas criminal actions are brought by the "Crown," i.e., the State. 19
In the case of criminal abuse of the older adult, the State has the authority to take legal action to protect the person from his or her abuser. It is also an offence under the Code not to provide the necessities of life to someone under a person's care. This provision is rarely used, and the need for it is being replaced through modem adult protection legislation.
One of the drawbacks of invoking the Criminal Code is that the older adult may be reluctant to seek help if he or she fears that the abuser may be subject to criminal action.
Physical assault
Financial abuse
Neglect
Mental cruelty
The provinces/territories have jurisdiction in areas such as family law, consumer protection and housing. Canada has two different legal codes; Quebec uses civil law, while all other provinces and territories use common law.
Although federal courts hear some federal matters, the administration of justice for both federal and provincial/territorial law is generally carried out by the provinces and territories. There are three levels of courts. The first level is the trial court, where all cases are tried. The second level is a provincial/territorial appeals court. The third level is the Supreme Court of Canada, which is the court of final appeal.
The provincial trial court system is broken down into divisional courts depending upon the nature and severity of cases tried e.g., small claims courts, involving small amounts of money, coroner's courts, juvenile courts, family courts and provincial Superior court. Six provinces (Nova Scotia, New Brunswick, Ontario, Manitoba, Saskatchewan and Alberta) have a surrogate or probate court which deals exclusively with the estates of deceased persons. 20
Proceedings at any of these courts could affect older adults.
Adult Protection Standards, Province of New Brunswick, October 5, 1993, Section 3, p. 1.
PRINCIPLES21
Adult protection services are to be delivered in accordance with the following three basic principles.
PRINCIPLE 1
All adults have the right to autonomy and self-determination and the right to enjoy the fundamental freedoms prescribed in The Canadian Charter of Rights and Freedoms.
PRINCIPLE 2
All adults are entitled to receive the most effective, least intrusive and least stigmatizing form of assistance.
PRINCIPLE 3
The use of protective care, court procedures and court orders should only occur as an absolute last resort and only after the provision of supports and assistance has been either attempted or carefully considered.
Adult protection legislation exists in New Brunswick, Newfoundland, Nova Scotia and Prince Edward Island. This type of legislation also is in place in Ontario and British Columbia, although it has not been proclaimed in force. Current protective legislation, which is being reviewed on an ongoing basis, is covered under the following acts:
Neglected Adults Welfare Act, 1973, no. 81
Family Services Act and the Amendment to the Act, 1980, c. F-2.2
Adult Protection Act, 1985, c.2, s.1
Prince Edward Island
Adult Protection Act, R.S.P.E.I. 1988 cap. A-5
Ontario
Substitute Decisions Act
British Columbia
Adult Guardianship Act, part 3
Display Summary 15 during presentation.
The following can be used in the review of provincial/territorial, procedures.
Presentation
The following synopsis of Atlantic adult protection legislation is an excerpt from an analysis in Adult Guardianship Law in Canada.22
In Newfoundland,
a declaration that a person is a "neglected adult" can be obtained from a judge of the Family Court or a Provincial Court judge ... however, a neglected adult is granted a right to appeal both the decision of the court and any act of the Director of Neglected Adults, to the provincial Supreme Court. Prior to deciding on an appropriate disposition, the court may order the removal of the adult to a hospital or other place without delay. However, a medical practitioner must first certify that, in his or her opinion, this course of action is necessary in the interest of the adult.
In New Brunswick,
social service personnel may apply to the Provincial Court for an order declaring an adult to be "neglected" or "abused" . . . Prior to the final determination of the case, the court may order the removal of the adult to a hospital or other place without delay, if a medical practitioner certifies that, in his or her opinion, it is necessary to do so in the interests of the person's health. The adult is granted the right to appeal any order or decision within 30 days to the Court of Appeal.
In Nova Scotia,
the Minister of Community Services may apply to the Family Court for an order declaring a person to be an "adult in need of protection" and either "not mentally competent to decide whether or not to accept assistance," or refusing assistance under duress. This conditional clause reflects the preference for the provision of assistance and protection on a voluntary basis ... In addition, the Minister may seek a "protective intervention order" to restrain a person who is a source of danger to the adult . . . Adults are granted the right to appeal to the Court of Appeal
In Prince Edward Island,
a protective intervention order may be sought from the Family Division of the Supreme Court in the case of an adult who is in need of either assistance or protection. If an adult has been determined to be "in need of assistance" and either refuses or is unable to give informed consent to assistance, or if a person exercising supervisory responsibility objects to the provision of the assistance, the Minister of Health and Social Services may apply for an order that the assistance be given as "protective intervention." The court may issue an order if it is satisfied that such a course of action is in the best interests of the adult. The Minister may also apply for a "protective intervention" order in the case of an adult determined to be "in need of protection," and the court may issue an order if it is satisfied that the person is in need of protection and the proposed intervention is in his or her best interests. In addition, and if certain conditions exist, the Minister may apply for, or promote an application for, the appointment of a guardian for the adult in need of assistance or protection.
The onus of showing the need for assistance or protection is placed on the Minister who must also be able to show that the order is the only remedy to the situation (i.e., a last resort), that protective intervention is in the best interests of the adult and that "the least intrusive and restrictive option practical is being sought." The statute is silent as to the standard of proof, the length of time between the application and the hearing, and the adult's right to appeal the issuance to a higher court.
Provision is made for the placement and care of an adult who has been determined to be in need of protection, in a hospital or other place, at any stage in the process of applying for a protective intervention order. The court may order such placement if it is satisfied that this course of action is essential to protect the adult's health.
[Reprinted by permission of Carswell - a division of Thomson Canada Limited (1992) Adult Guardianship Law in Canada]
Display Summary 16 during presentation.
Ask participants to discuss and compare adult protection provisions.
Presentation
The terms "guardianship" and "committeeship" are used in the different jurisdictions in adult protection legislation.
Although the terms [guardianship and committeeship] vary, they refer to a common set of circumstances: the appointment of a person or agency (e.g., a public trustee service) with the power and authority to take charge of the property, the financial affairs and, often, the physical persons of adults deemed to be "mentally incompetent, " "mentally incapable" or "mentally infirm" and therefore unable to make decisions on their own behalf 23
Legislation in the majority of provinces and the territories provides for the guardianship of the estate of an adult suffering from a mental disorder and admitted to a mental health facility. In most jurisdictions, the procedure is set out in mental health, legislation and generally involves the following steps. On admission, a patient is examined by a medical practitioner who determines whether the person is mentally competent to manage his or her affairs. If deemed incompetent, a certificate is issued and forwarded to the public trustee service. The service then assumes management of the adult's estate until such time as the certificate is cancelled by a medical practitioner or revoked by a mental health review board or court, or the court appoints a guardian of the estate.24
Each province and territory has methods of conferring guardianship. In Prince Edward Island, criteria are set in the Mental Health Act. The Nova Scotia Public Trustee Act also provides for guardianship of physically disabled adults. Newfoundland uses the Mentally Disabled Persons 'Estate Act as a means of protecting property, and New Brunswick has enacted the Infirm Persons Act which also extends to older adults not necessarily declared incompetent.
With the exception of Prince Edward Island, and, to a lesser extent, Nova Scotia, adult protection legislation makes no specific provision for the guardianship of an abused or neglected adult or his or her estate ... Certainly, adul tprotection statutes do not preclude the use of guardianship and it is noteworthy that, in both Nova Scotia and Prince Edward Island, an attempt has been made to synchronize adult protection and guardianship. In Prince Edward Island, the potential benefits of limited and temporary personal and estate guardianship appear to have been recognized and the legislation seems sound insofar as the guardianship option can be used at any stage in the intervention process. The principles of limited, tailor-made, and flexible guardianship are adopted. Both the need for a guardian and the scope of a guardian's powers and authority are to be determined by a comprehensive, multi-dimensional, functional assessment. This approach addresses the problem of protective "overkill, " at the expense of autonomy and self-determination. The same cannot be said for Nova Scotia where guardianship may be initiated through the agency of the Public Trustee. The focus is upon the protection of an abused or neglected adult's property and financial affairs, rather than the physical person, and no mention is made of the general principles adopted in Prince Edward Island which acknowledge that guardianship should be limited in scope. 25
In provinces with adult protection legislation, Nova Scotia law makes the reporting of abuse and neglect mandatory, while Newfoundland makes reporting of neglect mandatory. Prince Edward Island, British Columbia and New Brunswick have policies of voluntary reporting.
Proponents of mandatory reporting believe that it underlines the value of older adults in society and our responsibility to protect them from harm. It may also be a deterrent, since potential abusers would fear being reported and mandatory reporting may result in intervention taking place at an earlier stage in an abusive pattern.
Those opposed to mandatory reporting argue that it endangers confidentiality in many professional fields, violates client trust and privacy, and may make the abused person reluctant to seek help. There is also a fear that mandatory reporting puts in place a process which requires automatic and immediate investigation, increasing the danger of disrupting the older adult's life without sufficient grounds. As well, the lack of universal agreement about what constitutes abuse and neglect may make mandatory reporting more difficult.
In institutions with a unionized work force, the mandatory reporting of abuse or neglect can result in costly grievance procedures. This should not be an argument for not reporting and investigating institutional abuse. However, institutions need protocols, with the input of staff and management, to encourage a unified commitment to preventing abuse or neglect. It is especially important that everyone be educated on the aging process, conflict resolution and the prevention of abuse and neglect.
Both mandatory and voluntary reporting are ineffective if there is no public education program to inform people about the rights of older adults, the potential for abuse of those rights and the moral responsibility toward abused or neglected people. It is also necessary to provide adequate community resources to address the needs of the older adult and the rehabilitation of the abuser.
Display Summary 17 during presentation.
Engage participants in a discussion about mandatory and voluntary reporting, as well as the issue of confidentiality.
A power of attorney is a legal document in which a mentally competent individual designates another person to carry out certain transactions or make decisions while he or she is temporarily indisposed as a result of injury, physical illness or lengthy periods of international travel.27 The older adult can limit the power of attorney to certain tasks, such as selling the house or paying bills or it can also be extended to cover all financial matters. An adult can also name joint powers of attorney. These power of attorney provisions can be cancelled at any time and are invalid if the adult becomes incompetent.
If older adults are considering a power of attorney, they should choose carefully, be specific about the tasks to be performed and keep themselves informed about their affairs. Power of attorney documents could be safeguarded by lawyers, to be turned over under prescribed circumstances.
In all jurisdictions except Yukon and the Northwest Territories, provision for adults to donate enduring powers of attorney exist; that is, the attorney's authority will continue even if that adult becomes incompetent. This must be legally agreed upon and signed while the adult is still capable. In the majority of provinces, the enduring power of attorney can only be used in financial matters. However, in Nova Scotia and Manitoba, this power, or health directive as it is called, extends to the person, but only for health care decision making and does not include other personal matters. New legislation, in British Columbia and Ontario, provides for an equivalent. In Quebec, enduring powers of attorney, or "mandates for the eventuality of inability," are simply approved by the court (this is called homologation).28
The use of enduring powers of attorney can give the individual more choice than court-appointed guardianship, and can relieve the pressure on the family at the onset of serious debilitation. Knowing that the person handling the affairs of a loved one is a trusted friend or relative can give the older adult a sense of dignity and security.
Public trustee services may be appointed as guardian (or committee) to act on behalf of the adult who has been declared incompetent, even if there is an enduring power of attorney. The court's parens patriae jurisdiction overrides everything in this area of the law. However, the statutory committeeship (medical certification) procedure can be halted with an enduring power of attorney.
Prince Edward Island is an example of a province with an office of official trustee, and adults can voluntarily ask the official trustee for financial assistance and advice.
Display Summaries 18 and 19.
Introduce Case Study 16, "Abuse of Power of Attorney."
Presentation
Legislation in Nova Scotia, New Brunswick, Manitoba, Ontario, the Northwest Territories and Yukon generally affirms a mental health patient's qualified right to refuse medical treatment if [the person is considered] competent. If a patient is deemed not competent to give or withhold consent to treatment, such decisions are to be made by a substitute decision maker.29
The general right to refuse while competent (or not incompetent) exists in common law. Quebec, Ontario and British Columbia have enacted this right (not yet in force in Ontario and British Columbia, but still in existence in common law). A substitute decision maker is obliged (in common law, and by statute in some jurisdictions) to comply with any pre-expressed wishes of a patient before deciding on the basis of the person's best interests. The two are not necessarily the same but the patient's wishes, expressed while competent, must prevail. In some jurisdictions, a physician is required to get the consent of an incapable person's nearest relative before initiating treatment.
The provisions vary in each province and territory but the substitute decision maker in each case must make decisions that are in the best interests of the older adult, taking into account the known values of the person for whom he or she is making the decisions. This means conferring with others who are close to the patient.
1. Canada, Canadian Charter of Rights and Freedoms.
2. Gary Kenyon & Warren Davidson, "Ethics in an Aging Society" in Ethics and Aging (Ottawa: National Advisory Council on Aging, 1993), p. 22.
3. H.T. Brower, "Physical Restraints: A Potential Form of Abuse," Journal of Elder Abuse and Neglect, Vol. 4, No. 4 (1992), pp. 49-50.
4. Canada, National Advisory Council on Aging, "Use of Protective Restraints," Expressions, Vol. 9, No. 2 (Spring 1993), p. 6.
5. Kenyon & Davidson, p. 25.
6. Suanna Wilson, Confidentiality in Social Work: Issues and Principles (New York: The Free Press, 1978), p. 2.
7. Atsuko Karin Matsuoka, "Collecting Qualitative Data Through Interviews with Ethnic Older People," Canadian Journal on Aging, Vol. 12, No. 2 (Summer 1993), pp. 219-220.
8. Susan McMurray-Anderson & Rosalie Wolf, Elder Abuse and Neglect in the Family: Training Guidelines, (Massachusetts: University Centre on Aging, University of Massachusetts Medical Center, 1986), p. 3:1.
9. Michel Silberfeld and Arthur Fish, When the Mind Fails: A Guide to Dealing With Incompetency (Toronto: University of Toronto Press, 1994), p. 4.
10. William Harvey, "Ethics in the Health Care of the Elderly Person" in Ethics and Aging (Ottawa: National Advisory Council on Aging, 1993), p. 57.
11. Robert Gordon & Simon Verdun-Jones, Adult Guardianship Law in Canada (Toronto: Carswel-Thomson Canada Ltd., 1992), p. 1-2 1.
12. Silberfeld and Fish, p. 4.
13. Silberfeld and Fish, p. 4-5.
14. Canada, Mental Health Division, Community Awareness, p. 22.
15. Protocol Guidelines.
16. Canada, Health Services Directorate, Services to Elderly Patients, pp. 17-22.
17. Canada, Health Services Directorate, Services to Elderly Patients, p. ,
18. Canada, Health Services Directorate, Services to Elderly Patients, 5.2.2, p. 91.
19. Canada, National Advisory Council on Aging, "Canadian Law: A Primer - The Courts." Expressions, Vol. 6, No. 4 (Summer 1990), p. 2.
20. Canada, National Advisory Council on Aging, "Canadian Law," p. 2.
21. Government of New Brunswick, Adult Protection Standards (October 5, 1993), Section 3, p. 1.
22. Gordon & Verdun-Jones, p. 2-26 to 2-28.
23. Gordon & Verdun-Jones p. 1-2 to 1-3.
24. Gordon & Verdun-Jones, p. 3-58.
25. Gordon & Verdun-Jones, p. 2-52 & 2-53.
26. This section on mandatory/voluntary reporting has been adapted from the following sources: Canada, Mental Health Division, Community Awareness, p. 27-28; Gerontology Research Centre, Simon Fraser University, "SSHRC Ethics Proposal" (unpublished document, 1993); and Gordon & Verdun-Jones, 2-47 to 2-51.
27. Robert Gordon, "Material Abuse and Powers of Attorney in Canada," Journal of Elder Abuse and Neglect, Vol. 4, No. 1/2 (1992), p. 178.
28. Gordon, p. 176-178.
29. Gordon & Verdun-Jones, p. 3-82.
Module I: Personal Empowerment
Module II: Advocacy
Module III: Support
Module IV: Education
To suggest strategies older adults can use to prevent abuse and neglect.
Presentation
Abuse and neglect may be reduced by exploring new ways to solve problems, by dealing with stresses and changes in our lives, and by clearly communicating our wishes to each other. We begin to reduce the possibility of abuse happening by organizing our lives before we are in a situation where we are dependent on someone else.'
Older adults are independent for varying amounts of time. Eventually, many may require help from others with some aspects of their daily living. Adults can prepare for this transfer of responsibilities by making decisions in advance of any debilitation.
Display Summary 20 during presentation.
Have participants consider ways in which the quality of life of older adults can be improved. It is important for participants to see themselves as pan of the prevention process.
Learning to accept loss of control in some areas of your life and being willing to accept help is not always easy to do. If you do not recognize your feelings and talk about them, communication can break down and possibly lead to a situation of abuse and neglect.
Presentation
Up to this point, the main focus has been on identification and response to cases of abuse and neglect of older adults. However, as Canadians learn to recognize the factors that lead to this problem, the underlying causes can be addressed, and preventive efforts can become the goal. This means:
Advocacy is the vigorous and systematic representation of the views and special needs of older people to those in authority. Advocacy affirms the dignity and rights of people who are in danger of being devalued, ignored or harmed by the structures and systems of society.2
Until Ontario passed its recent Advocacy Act and its Ontario Substitute Decisions Act, there were no legislative models for advocacy. However, that is not to say there were not community and organizational models. Public advocates have been working vigorously for several years, publishing newsletters, lobbying for the funding of new services for older adults, and helping to improve the social networks vital to their quality of life and continued independence.
These advocates have looked for long-term solutions, while at the same time addressing immediate needs of the older population. As a tool for prevention, advocacy is most effective when it involves a wide cross-section of the community.
They can also lobby for professional standards and accountability within their communities to reflect a caring approach to the needs of older adults, especially those who are vulnerable to abuse or neglect.
Members of the wider community can act as public advocates for these changes. For instance, people can be vocal and persistent about the growing need across the country, for personnel trained to deal with abuse and neglect of older adults. They can also call for more counselling and support services in the field of home care.
Service providers can network with their peers across the country, sharing information, policy approaches and program initiatives. They can also serve on national organizations that promote programs for the prevention of abuse and neglect, and help in publicizing the work of these organizations.
Display Summaries 21 and 22 during presentation.
Presentation
The autonomy of older adults is one of their basic rights, and the protection of this right plays a major role in the prevention of abuse and neglect. Communities can help to support service providers, families and caregivers in their efforts to improve the quality of life of older adults. Service providers can also support efforts to improve the delivery of services.
Individual seniors, families, non-profit organizations, private enterprise and the public sector depend on one another and are responsible to one another. Certainly, the ability of any partner to fulfil its role with respect to seniors' independence and autonomy depends upon the support of the others. A concerted and collaborative effort is required to maintain the independence and autonomy of seniors in the community.3
Communities can benefit from the experiences of older adults, while providing them a sense of their continuing value as contributing members of society. An excellent example of this would be the conscious inclusion of older adults as resource people in the Girl Guide, Boy Scout or 4-H programs.
Allow residents to keep some of furnishings or personal possessions in their rooms. Help and encourage residents to keep up activities and hobbies they enjoy, as long as they are able. For instance, residents can have ready access to books and cards.
It is very important that staff at long-term facilities offer a wide range of activities and recreational programs, especially for frail, older people, who may need help to participate. On the other hand, care should be taken to ensure that older adults are not forced to take part in programs if they do not wish to do so.
Display Summaries 23 and 24 during presentation.
Presentation
Perhaps the most effective way to promote long-range prevention of abuse and neglect is through education and training. A public awareness program, however, has many components, and it must be able to describe the situation adequately.
Therefore, it becomes important to collectively decide on standard definitions for the various forms of abuse and neglect, criteria for incompetency and levels of decision making by older adults. Attitudes toward aging and the effect of these attitudes on the rights of older adults must also be examined. Finally, public education programs are required to examine the risk factors, causes and strategies to prevent abuse and neglect.
Individuals who work in the community, such as homemakers, doctors, visiting nurses, as well as volunteers and apartment managers, may observe couples who fight, old adults living in squalor, relatives who take over property, or other abusive situations. They may wish to support the victim but often do not know what to do or are reluctant to interfere with family relationships.... Training community workers to identify risk factors, to assess family dynamics and how to stay involved with the cases is of primary importance.5
This ongoing approach to case management can enhance the abilities of all members of the team to respond to the needs of abused or neglected older adults.
Long-range prevention needs to emphasize basic "family life" education related to:
the aging family and couple relationships; positive contacts with older adults; stress management; communication skills; and financial management.
The benefits of family life education would be to
Finally, to raise public awareness about issues related to abuse and neglect, the concept of zero tolerance of abuse and neglect of older adults need to be promoted. Community members can organize public forums, circulate published material, and encourage the media to broadcast public service messages.
Display Summary 25 during presentation.
Have participants suggest examples of programs to help older adults, particularly programs from their own community.
Divide participants into groups and ask each group to suggest a program that could be undertaken by one of the following organizations/businesses to increase the autonomy, self-esteem or security of older adults.
Pass out a list of community resources for your area.
1. P.E.I. Association of Social Workers, Learning Today, p. 38.
2. Canada, Mental Health Division, Community Awareness, p. 20.
3. Blossom Wigdor & Louise Plouffe, Seniors' Independence, Whose Responsibility? (Ottawa: National Advisory Council on Aging, 1992), p. 17.
4. Canada, Seniors Secretariat, "Managing," p. 6-7.
5. Elizabeth Hamlet, "Training Professionals to Deal With Elder Abuse," in Family Violence: Perspectives on Treatment, Research and Policy, eds. Ronald Roesch, Donald G. Dutton and Vincent F. Sacco (Burnaby: British Columbia Institute on Family Violence, 1990), p. 3-4.
Abuse and neglect of older adults is a complex issue that has serious impact on the well-being and quality of life of older adults. Service providers can have an important role to play in identifying, intervening and preventing abuse and neglect. This kit gives trainers some valuable tools to raise awareness among service providers. It describes the current understanding of abuse and neglect of older adults, and identifies a number of issues for service providers.
Identified issues include:
Increasing awareness of abuse and neglect is an important first step in building support for programs and services. Preventing abuse and neglect of older adults is a community challenge and everyone's responsibility. Service providers can help create an environment that supports and enhances the quality of life of older adults.
We wish you well in this important work. Please let us know ways in which you use this Resource and Training Kit for Service Providers, and your assessment of its value by completing the evaluation form found in Appendix A, and returning it to the Mental Health Division, Health Canada.
[Reproduced by authority of the Minister of Industry, 1994, Statistics Canada, General Social Survey, 1990 & Canadian Social Trends. No. 20 spring 1991 and No. 29 summer 1993.]
"Age Structure of the Population, Actual and Projected, 1950-2050"
Canadian Social Trends, Vol. 20 (spring 1991), p.6.
"Projected Population, by age group, 1992 to 2036"
Canadian Social Trends, Vol. 29 (summer 1993), p.6.
"Percentage Who Had Parents or Children Alive and
Who Lived with Them, by Age, Canada, 1990"
General Social Survey (1990) Statistics Canada
Readers wishing additional information on data provided through the cooperation of Statistics Canada may obtain copies of related publications by mail from:
Publication Sales, Statistics Canada, Ottawa, Ontario, KIA 0T6 or by calling (613) 951-7277 or toll-free 1-800-267-6677. Readers may also facsimile their order by dialing (613) 951-1584.
To add life to the years that have been added to life
[Adopted by the United Nations General Assembly Resolution No. 46/91]
1. Older persons should have access to adequate food, water, shelter, clothing and health care through the provision of income, family and community support and self-help.
2. Older persons should have the opportunity to work or to have access to other income-generating opportunities.
3. Older persons should be able to participate in determining when and at what pace withdrawal from the labour force takes place.
4. Older persons should have access to appropriate educational and training programs.
5. Older persons should be able to live in environments that are safe and adaptable to personal preferences and changing capacities,
6. Older persons should be able to reside at home for as long as possible.
7. Older persons should remain integrated in society, participate actively in the formation and implementation of policies that directly affect their well-being and share their knowledge and skills with younger generations.
8. Older persons should be able to seek and develop opportunities for service to the community and to serve as volunteers in positions appropriate to their interests and capabilities.
9. Older persons should be able to form movements or associations of older persons.
10. Older persons should benefit from family and community care and protection in accordance with each society's system of cultural values.
11. Older persons should have, access to health care to help them to maintain or regain the optimum level of physical, mental and emotional well-being and to prevent or delay the onset of illness.
12. Older persons should have access to social and legal services to enhance their autonomy, protection and care.
13. Older persons should be able to utilize appropriate levels of institutional care providing protection, rehabilitation and social and mental stimulation in a humane and secure environment.
14. Older persons should be able to enjoy human rights and fundamental freedoms when residing in any shelter, care or treatment facility, including full respect for their dignity, beliefs, needs and privacy and for the right to make decisions about their care and the quality of their lives.
15. Older persons should be able to pursue opportunities for the full development of their potential.
16. Older persons should have access to the educational, cultural, spiritual and recreational resources of society.
17. Older persons should be able to live in dignity and security and be free of exploitation and physical or mental abuse.
18. Older persons should be treated fairly regardless of age, gender, racial or ethnic background, disability or other status, and be valued independently of their economic contribution.
[Reprinted with permission from the P.E.I. Association of Social Workers. Elders Ourselves [booklet]. Charlottetown: P.E.I. Association of Social Workers, 1991.]
To be used with the video Elders Ourselves, produced by ATV and Theatre P.E.I.
Projections indicate that, by the year 2001, 14% of the total Canadian population will be 65 or over.
For many who reach retirement age the years ahead are full of promise. For them, the future looks exciting. It offers all kinds of opportunities for new ventures or the chance to do nothing in particular - with lots of time for both.
Even though it is true that the majority of today's elderly are fit and happy, there are those for whom aging brings problems and concerns. They sometimes find themselves in living situations not of their choosing. Elderly individuals may have no alternative but to leave their home and move in with a family member. They can unintentionally be made to feel "left out" - a member of the family but no part of it.
The video, Elders Ourselves, attempts to show some of the tensions that can build up in these situations. The goal is to encourage public discussion and promote better understanding of the reasons behind abuse of the elderly.
On a more personal level, the video is an attempt to lead caregivers and the elderly to recognize two important things:
Communication is sadly missing in the story of "The Family." Vera is tired and harassed. She feels resentful of this unexpected role she finds herself in, and she's not quite clear about what she is supposed to do within it.
Her role as a mother she understands. She feels quite justified in openly disciplining her children and is comfortable being in a position of authority over them. As a wife, too, she knows where her guidelines are. But as a caregiver of her husband's mother, she is very unsure of herself and, in her uncertainty, resorts to the behaviour pattern she knows best, that of a person in authority. So we see her treating Lilly like a child when the old lady cannot eat her meal, and the sad consequences follow.
Women are often the ones who provide the care for elderly relatives. In earlier times, this was seen as a clear role for women who were working in the home, frequently as caregivers. Society has seen many changes during the last fifteen years. It is now commonplace for women to have a full-time career as well as a full-time family. This new system of organizing family life can work well when everyone knows their roles within it. However, with the arrival of Lilly, Vera's carefully balanced routine is suddenly weighted too heavily on her side, and she finds that she is doing far more than she considers her fair share. She feels resentful and angry, and even though Lilly is capable of doing a lot for herself still, Vera does not see that as she struggles from day to day with the stress of her extra workload.
As the short story progresses, tension grows around the table: the sharp voices, the short, abrupt sentences, the rising volume of Vera's demands as she puts herself, and Lilly, into an unavoidably confrontational situation.
If Vera and Lilly had talked to each other of their needs and if each had made genuine efforts to hear what the other person was saying, then perhaps the violence would not have erupted in the way it did.
It is not difficult to understand Vera's frustration. She is taking care of her family in the way she always has. But, with her independence under threat as she realizes that Lilly will be with the family for a long time, she finds it too painful to accept the implications, and so takes it out on those closest to her.
This video was produced as part of a larger project, Learning Today for a Better Tomorrow with the intention of highlighting the plight of many elderly people who are living in abusive or neglectful situations.
The project was sponsored by the Prince Edward Island Association of Social Workers and funded by Health Canada under the auspices of the Seniors Independence Program.
The documentary was produced at ATV Halifax, with the co-operation of Theatre PEI.
Each story is complete in itself. It is possible to stop the film after each one to allow discussion to take place. There are some suggested questions following each section in the guide.
Before viewing the video, try to imagine yourself as an elderly person. Think about the future; think about growing old.
[Adapted with permission from P.E.I. Association of Social Workers. You the Caregiver. Charlottetown: Tea Hill Press, 1991, pp. 10-11.]
It is important for the older adult, his or her family or friends to assess the situation realistically before making changes in living arrangements. There are many things to consider before deciding to share a home.
[Reprinted with permission from Charmaine Spencer. Article in Gerontology Research Centre News. Burnaby: Simon Fraser University. Vol. 11, No. 4, March/April 1993, p. 4.]
Although financial abuse is considered to be one of the most common forms of abuse that the elderly people endure, we still do not know what we mean by "financial abuse."
Acts which break the law are unquestionably abusive. Criminal law prohibits people from intimidating, threatening or harassing others to get money, property or possessions. Civil (common) law prohibits using undue pressure, coercion, fraud or misrepresentation to get people to sign documents or otherwise hand over assets. But beyond the obvious category of the illegal, are there other actions which should be considered to be financial abuse?
In order to clarify our analysis, let's look at some hypothetical cases.
If a charity or new friend convinces an older person to give them their money, we may think that the older person was gullible and unable to say no. Are we thereby assuming mental incapacity in the elderly? If the new friend is considerably younger and of the opposite sex, are we not implying that the older person is too gullible to know what an appropriate friendship or love relationship is?
We can accept that a 20-year-old son may borrow money from his 50-year-old parent and not repay it, but if the son is 47 and tile parent 77, we may not accept such an arrangement. What does this reveal about our social attitudes? We seem to hold that a 47-year-old should be financially independent of his parents and that, if he is not, there must be something pathological in the relationship. Or, are we
merely hypothesizing that a middle-aged father still has time to recoup his loss, whereas the older person does not?
More remarkably, why is it that in western society grown children are not expected to provide needed financial support to their aging parents? Many parents contributed significantly to ensure that their children would enjoy a higher standard of living than they themselves did.
Why are we more likely to consider the taking of an older woman's pension cheque as financial abuse than the taking of the same money from a man? Are we making sexist assumptions that older women are more vulnerable? Or are we recognizing that, because women face discrimination in wages, pension benefits and capital resources throughout their lives, financial abuse may have a more devastating impact on them?
Finally, why does it seem natural to question the mental competence of older people who want to spend a substantial portion of their financial resources, for example, to invest in a relative's high-risk business venture?
Our responses to these hypothetical cases reveal that we make many assumptions about aging, relationships and social responsibility. There is an underlying belief that older adults have a social duty to preserve their financial resources, and that we may intervene when there is a risk of their becoming homeless or dependent on the state.
[Reprinted with Permission from the P.E.I. Association of Social Workers. Elders Ourselves (booklet). Charlottetown: P.E.I. Association of Social Workers, 1991.] To be used with the video Elder Ourselves, produced by ATV and Theatre P.E.I.
There are many different kinds of family relationships. While it is important to remember that although many of the elderly are women, there are also many older men who find themselves in vulnerable positions.
This has happened to Ken, who has been staying with his nephew, Lester, and Lester's wife Joanie, until his health returns. Ken spends his days either in his room, or in the basement, painting landscapes. While he has been recuperating from his injury, Lester has been handling Ken's financial affairs.
Now that Ken is almost fully recovered, he wants to take charge of things for himself again, and it is from this viewpoint that we see the tension between Ken and Lester.
For many people it is very important that they be able to "pay their own way," and not "be beholden" to anyone. Lack of access to their own money means, in many instances, lack of independence. It also means lack of freedom to make choices and an increase in vulnerability.
This vulnerability is evident in the video. Ken is now capable of handling his own affairs, but Lester either does not believe this, or prefers to ignore it. They do not communicate well with each other and the result is misunderstanding, anger and the frustration that can be the beginnings of an abusive situation.
RESOURCE 7 - SECTION FOUR, MODULE IV
ABUSE AND NEGLECT INDICATORS
[Adapted with permission from the British Columbia InterMinistry Committee on Elder Abuse, and Continuing Care Division, Ministry of Health and Ministry Responsible for Seniors. Principles, Procedures and Protocols for Elder Abuse, February 1992, P. Xxiii.]
|
Category of Abuse and Neglect |
Indicators |
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Physical abuse |
- unexplained injuries such as bruises, bums or swellings - injury for which the explanation does not fit the evidence - delay in seeking treatment (although this is neither common nor serious) - injury to scalp (evidence of hair pulling) - symmetrical grip marks (evidence of shaking) |
|
Psychological or emotional abuse |
- fear - withdrawal - low self-esteem - extreme passivity - appears nervous around the caregiver/family member |
|
Financial abuse or exploitation |
- unexplained discrepancy between known income and standard of living - an older adult has signed a document (e.g., will, property deed) without full understanding - possessions disappearing - if you work in a financial institution: an older adult is surprised by an overdrawn or lower-than-expected bank balance; unusual transactions conducted on behalf of an older person |
|
Sexual abuse |
- pain, bruises or bleeding in genital area |
|
Medication abuse |
- reduced mental or physical activity - depression - reduced/absent therapeutic response |
|
Denial of civil/human rights |
- difficulty visiting, calling or otherwise contacting an older adult - older adult makes excuses for social isolation |
|
Neglect/self-neglect |
- malnourished, dehydrated - missing dentures, glasses, hearing aid - unattended for long periods or tied to bed/chair - unkempt appearance, dirty or inappropriate clothing - untreated medical problems |
[Reprinted with permission from the Ontario Association of Professional Social
Workers. Basu, Ranjy. Elder Abuse: A Practical Handbook for Service Providers.
Toronto: Ontario Association of Professional Social Workers, 1992, pp. 21-29]
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FACTORS |
CHECK FOR |
EXAMPLE QUESTIONS |
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Elder [older adult] and caregiver |
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FACTORS |
CHECK FOR |
EXAMPLE QUESTIONS |
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Elder [older adult] and caregiver |
Give a relevant hypothetical situation and check for:
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FACTORS |
CHECK FOR |
EXAMPLE QUESTIONS |
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Attitudes toward elder [older adult] and caregiving |
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Understanding of elder's limitations and care needs |
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Health |
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Personality characteristics |
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Life stages and stressors |
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| Finances |
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FACTORS |
CHECK FOR |
EXAMPLE QUESTIONS |
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Current/pre-existing personal/family issues |
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Views re: care of elderly people |
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Job satisfaction |
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[Reprinted with permission from the Government of Nova Scotia, Department of Community Services.]
Intake Form
Office Worker
Date Time a.m./p.m.
Adult's Name Age
Address
Home for Special Care? ( ) Yes ( ) No
Telephone Number
Is adult physically disabled? Yes No
Mentally Infirmed? Yes No
Type of disability/infirmity?
Referred by
Confidential? ( ) Yes ( ) No
Address/Agency
Telephone Number Relationship to Adult
Neglect or ( ) Abuse If abuse, type suspected
Alleged Abuser
Name
Address
Telephone Number Relationship to Adult
Signs of neglect/abuse, i.e. what has been heard, and by whom?
Collateral Contacts:
Names Addresses Telephone # Relationship
Urgency of Assessment: ( ) within 24 hours ( ) within 2 days ( ) within 5 days
Case referred to Date
Signature
Office Worker
Date Time a.m./p.m.
Referral Source Telephone
Alleged Concern: (From Intake and Inquiry Form)
Client Information:
Name
Address
Telephone # S.I.N. #
M.S.I.#
Date of Birth Age
Marital Status: ( ) Married ( ) Divorced ( ) Single ( ) Widowed ( ) Separated
Is Client - Physically Disabled Yes ( ) No
Mentally Infirm Yes ( ) No
If Yes, please describe
Next of Kin or Emergency Contact
Relationship Telephone #
Physician Telephone #
Medications and Adult's Knowledge of Usage
Client Living Situation:
A. ( ) Own Home or ( ) Apartment
i) Does Client Live:
Alone
With Relatives - Names and Relationship
( ) With Friends - Names
ii) Who owns home?
Clients
Relative/Friend - Name
( ) Joint Ownership - Name
B. Names and Relationships of Others Living in Home
Client Financial Information:
Who handles Client's finances?
( )Client
( ) Other - Name and Relationship
Does Client receive
Total Amount of Income
Allowance - Amount
Total Income
Income Sources
Total Expenses:
Is Client under Guardianship ( ) Yes ( ) No
Name and Relationship of Guardian:
Telephone #
Has Power of Attorney been granted? ( ) Yes ( ) No
Name and Relationship of P.O.A.:
Telephone #
Is the Public Trustee Involved? Yes No
Type of Involvement
Risk Indicators in Relation to Adult:
Visible signs of abuse (bruises, cuts, etc.)
Visible signs of neglect (poor hygiene, malnutrition, etc.)
Unexplained or repeated injury
Mental/physical disability limiting ability to care for or protect oneself
Overdependence on caregiver
Signs of duress
Social isolation
Geographic isolation
Passive/withdrawn beaviour
Presence of alcohol/drugs
Comments on Above:
Worker's Assessment Based on Interview with Adult and/or Observation of Adult:
e.g. i) Describe general condition of environment
ii) Describe general condition of adult (physical appearance, presence of physical/ mental disabilities interfering with care requirements or preventing adult from protecting himself/herself.)
Caregiver Information:
Name Relationship to Client
Address
Telephone # Age
Employed: ( )Yes ( )No Occupation
Marital Status: ( ) Married ( ) Divorced ( ) Separated ( ) Single ( ) Widowed
Risk indicators in Relation to the Caregiver:
Incapable of providing care due to mental/physical disability Unrealistic expectations concerning care requirements Under stress Contradictory information Delay in seeking care for the adult Attitude toward adult (tolerance) Presence of alcohol/drugs
Worker's Assessment Based on Interview with Caregiver and/or Observation of Adult/Caregiver Interaction:
On basis of Assessment, is Follow-up Action Required? ( ) Yes ( ) No
If "Yes", please indicate proposed plan of action and follow-up date, i.e. referral to community agency, medical assessment, further interview with adult and/or caregiver.
Proposed Plan of Action:
Follow-up DATE:
If "No", please indicate reason:
Signature of Worker Performing Assessment Date
Signature of Supervisor Date
Adult's Name:
Address:
MR:
Please state your professional opinion on the following questions. Provide as much detail as possible.
1. Check appropriate box and initial:
Is this person an "Adult in Need of Protection" as defined below?
( ) Yes ( ) No
In this Act,
(a) "Adult" means a person who is or is apparently sixteen years of age or older;
(b) "Adult in need of protection" means an adult who, in the premises where he [she] resides,
(i) Is a victim of physical abuse, sexual abuse, mental cruelty or a combination
thereof, is incapable of protecting himself [herself] therefrom by reason of
physical disability or mental infirmity, and refuses, delays or is unable to
make provision for his [her] protection therefrom, or
(ii) Is not receiving adequate care and attention, is incapable of caring adequately
for himself [herself] by reason of physical disability or mental infirmity, and
refuses, delays or is unable to make provision for his [her] adequate care and
attention;
2. Does the adult appear to be receiving adequate care and attention?
3. Is there any evidence that the adult is a victim of abuse (physical, sexual, and/or mental cruelty)?
4. What is the mental and physical state of the adult insofar as it may affect the adult's capability to care for or to protect him/herself?
5. Please check and initial
Is the Adult Mentally: Competent Incompetent
If mentally incompetent, please elaborate:
6. What do you recommend as an appropriate care plan for this adult? (i.e. In-Home Support Services, Placement in Home for Special Care, etc.)
Signature
Telephone Number:
Printed Name:
Date:
[Adapted with permission from P.E.I. Department of Health and Social Services, Division of Home Care and Support. Abuse/Neglect Protocol. Charlottetown: 1987.]
The following protocol is part of an internal protocol developed for and by people who work with older adults. It does not necessarily reflect legislated obligations or rights. It is an example of one type of protocol and can be used as a model for discussion.
The purpose of this protocol is to provide information and guidelines to assist home care and support staff in identification and intervention in situations where there is concern for the physical, emotional or material well-being of an adult. It is designed to help workers respond with due consideration to the complexities of adult abuse/neglect; to clarify some of the moral, ethical and legal issues; to outline action responsibilities; and to direct appropriate referrals.
1. Every situation involving suspected abuse or neglect must be assessed individually to determine the best interests of the person(s) involved and the degree of intrusion warranted. Situations will vary widely in. degree of risk to the adult person.
2. People have the right to the basic requirements of life - food, clothing, shelter and social contact. The right to receive is not equivalent to the obligation to receive.
3. People have the right to participate freely in a lifestyle of their choice provided that lifestyle does not infringe on the rights and safety of others.
4. People have the right to protection from physical, emotional or financial abuse.
5. People have the right to information about their civil and legal rights, to safety and security, to options or choices open to them and to have their decisions or choices respected. Although not all these rights are necessarily defined in law, they are principles which can govern the conduct of relationships between people.
6. People have the right to participate in decision making regarding their well-being and safety in accordance with their ability to do so. This principle is not only basic to our culture but therapeutic and supportive to ongoing autonomy. Unilateral or paternalistic protection services convey messages of incompetence and frailty.
7. People have the right to the least restrictive or intrusive intervention. If this principle is violated by intervenors being hasty with accusations, or judgmental in their approach, this could have a negative effect on the situation. These responses can be disruptive and counter-productive to a person's health and welfare, occasionally resulting in further injury, abandonment by family or community, or premature institutionalization.
8. Intervention should be aimed at maximizing the person's or family's options, and should be based on the person's or family's strengths and abilities for positive action.
9. Intervention can only be undertaken with the voluntary and informed consent of the person. If the person is competent, action plans must be developed with his or her participation.
10. Recognition and disclosure of abuse and neglect are complicated by fear, ignorance and embarrassment. Staff can commonly expect victims to display passivity, poor self-esteem and indecisiveness. Initiating change will often require time for the development of a quality reciprocal relationship characterized by mutual respect.
11. A non-accusatory approach is the key to voluntary protective services. Identifying the needs of the caregiver and the receiver, and facilitating or negotiating a resolution to these needs will optimize the end results.
12. Commitment to a co-ordinated response enhances the resolution of most cases. Intervenors should aim to balance ethical duties to care and provide care with respect for the person's rights and freedoms.
[Reprinted with permission from the Government of Newfoundland, Department of Health.]
In keeping with provincial legislation, departmental policy, accreditation and professional standards, protocols on abuse of persons are required by all agencies under the auspices of the Department of Health. The following guidelines are provided to facilitate protocol development.
a. Public awareness
b. Community initiatives/programs
c. Screening/identification of individuals and/or families at risk
a. Duty to report (who? what? when? To whom?)
b. Documentation
c. Handling of disclosures
d. Individual in need of protection
e. Referral (role of different disciplines)
a. Criminal investigation
b. Role in legal proceedings
a. Assessment procedures
b. Referral
c. Treatment
a. Multi-disciplinary approach (case management, co-ordination)
b. Case review
c. Case termination
d. Evaluation
a. Orientation
b. Inservice and continuing education (multi-disciplinary, interagency)
[Adapted with permission from HomeSupport Canada. Responding to Elder Abuse: A Guide for the Development of Agency Protocols for the Home Care and Community Support Sector. Ottawa: HomeSupport Canada, 1994, pp. 13-15.]
A reporting mechanism and decision-making authority should be established within the organization. Any suspicion of abuse or neglect should be reported to be dealt with appropriately.
[Reprinted with permission from the Department of Health and Community Services, Government of New Brunswick. "Casework Guidelines." Adult Protection Standards. October 5,1993. Section 8, pp. 1-3.]
Where possible the case plan should be developed in consultation with the client and his or her family or support system. The intervention should be planned, purposeful and employ the least restrictive alternatives.
1. A case plan is to be completed within a month of receiving the referral.
2. The case plan developed is to be individualized, time-limited and goal-oriented and should:
- identify the main problem(s);
- outline steps to ensure the immediate safety of the individual, where appropriate;
- indicate whether service is voluntary or involuntary;
- specify the type of order to be requested, where appropriate;
- identify the goal(s) and service objectives and the time periods anticipated for their completion;
- list the major activities to be undertaken and specific services provided; and
- identify the review dates and plans for follow-up.
3. All significant activities, events or changes occurring in the case shall be recorded.
4. Each case is to be monitored on an ongoing basis and a review is to be undertaken a minimum of every three months; the results are to be recorded.
There are situations in which a mentally incompetent adult does not have anyone who is able or willing to take care of him or her; for example (a) an elderly person who does not have any living relatives, (b) an individual who has been in the care of the Minister, perhaps since birth, or (c) someone who has been in a psychiatric facility for many years and is about to be discharged.
In instances such as these, the worker will have to apply for Trusteeship Order under sections 37.2 or 39.1 or 39.2 of the Act. Once such an order is granted, arrangements may be made for the actual day-to-day care of the person and the management of the estate to be undertaken by another person or agency. However, the Minister retains full responsibility for the care and supervision of the individual and his or her estate and, therefore, the case must remain open until the client is deceased.
A case is to be closed under any of the following circumstances.
1. The client is receiving the required care and either the client, or his or her family/support system, demonstrate the capability and intention of avoiding future neglect either through his or her own resources or by making alternate arrangements.
2. The client is at no risk or low risk of further injury or harm.
3. The client is deceased, unless the death is suspected to be the result of abuse or neglect.
In situations involving a court order other than a Trusteeship Order, the closure of the case should coincide with the expiration of the order. If there is a substantive amount of time left until the order expires, the worker should make an application under section 39(6) of the Act to have it terminated.
When closing a case, the worker is to:
1. Ensure that any required follow-up effort has been arranged.
2. Advise the adult/family accordingly and tell them the reason(s) for closure.
3. Make the necessary referrals for service.
4. Document the reason(s) for closure on the individual case file.
[Reprinted with permission from the InterMinistry Committee on Elder Abuse and
Continuing Care Division, Ministry of Health and Ministry Responsible for Seniors.
Principles, Procedures and Protocols for Elder Abuse, February 1992, ii-xxii.]
1995 Ministry of Health updates noted in square brackets
Home support agencies provide homemaker services which assist clients with health related disabilities to continue living in their own home. The homemaker can provide personal assistance with daily activities, such as bathing, dressing and grooming. The homemaker can also assist with various household tasks, including laundry, vacuuming, cooking, etc.
Courtesy of Fernwood Home Support Services Society Victoria, British Columbia
Any form of client abuse will not be tolerated. [This policy is also to alert staff to abusive situations in the home.]
For the protection and well-being of both clients and staff members, the following shall apply:
I . It is essential that every employee recognize the client's right to dignity and proper care.
2. Abuse includes:
Acts of commission or deliberate omission by a person or persons on a client that result in the unwarranted physical pain, injury, physical coercion or confinement such as being hit, slapped, bruised, sexually molested, cut, burned or physically restrained. Also, debilitating psychological or mental anguish such as being humiliated, treated as a child, frightened, intimidated, threatened or isolated. [For a more comprehensive listing, including financial abuse, refer to Principles, Procedures and Protocols for Elder Abuse.]
3. In the event of a client reacting unfavourably or refusing normal or necessary assistance, patience and understanding will be required.
4. Do not attempt to overcome the resistance unless the client is in immediate danger of physical harm. Never reciprocate aggression.
5. If a situation arises which an employee feels incapable of handling, the employee is instructed to request the assistance of a supervisor immediately.
6. In the absence of supervisory personnel, employees are to call the office and inform other office personnel.
Courtesy of the Department of Social Work Greater Victoria Hospital Society
Patient is 65 years or older, and definitely diagnosed as being abused physically, sexually, emotionally or financially, is a suspected case of elder abuse or has unexplained physical symptoms.
Emergency Measures (Recorded)
- Review referral, chart, and any other pertinent, written information.
- Consult with staff involved.
- Interview patient alone.
- Interview caregiver or other significant person (with patient's permission) alone.
- Demographic data.
- Living conditions, income, ability to do self-care, typical day, outside contact, tasks done by others, degree of support given by caregiver, directly quote whether patient has ever been hit, had food or medications withheld, been oversedated, had money or property removed, or fears being left with caregiver.
- Patient's view of problems and possible resolution.
- Corroborative evidence to establish patient's mental functioning, e.g., Goldfarb Dementia Scale.
- Patient's motivation and consent to explore situation further with relatives/collateral sources/others involved.
- Demographic data and reason person involved in patient's care.
- Typical day, caregiver's perception of patient; expectations of patient and degree of support given, other resources used.
- Caregiver's knowledge of patient's health and care needs.
- Explore difficulties caregiver encounters and his or her response.
- Caregiver's knowledge of alternative resources available.
- Caregiver's view of the problems and possible resolution.
- Social worker's impression of patient and caregiver, and the implications for discharge planning
Plan (To be recorded)
- Liaison nurse/community assessor for Continuing Care Division assessment for placement or home supports to relieve home situation.
- Transition house for immediate shelter out of patient's home (women only).
- Police re: laying charges.
- Lawyer/Law Centre for advice.
- Geriatric short-stay assessment units at Fairfield Health Centre or Royal Jubilee Hospital for full multi- disciplinary assessment.
- Counselling - patient and/or family or caregiver by social worker.
- Next-of-kin (especially if out of town).
- Government agencies re: finances, e.g., Public Trustee.
- Health care team for consultation.
- Geriatric psychiatrist for competency assessment/treatment.
- Outline plan in care plan on chart.
- Follow case until problems resolved and/or discharge plan agreed upon by patient, caregiver and health team, or patient dies or terminates social work intervention.
- Contact patient by phone within one week of discharge and review situation.
- Contact professional who will follow situation in community, e.g., Continuing Care Division Assessor, doctor, home care nurse.
Implementation Process (Not recorded)
Outcome (To be recorded)
III. Criteria for Terminating Social Work Intervention (To be recorded)
A non-profit community agency which offers a variety of services, including general information, referral, volunteers, legal and financial counselling services, and public education programs.
Courtesy of North Shore Community Services North Vancouver, British Columbia
The right to self-determination is paramount.
A person is competent and capable unless legally declared incompetent or certified incapable.
Instructions regarding individuals and their affairs are to be taken from the elderly person himself or herself, rather than from a family member or other person purporting to be acting for the elderly person.
Often an initial report of abuse is clouded by justification i.e., caregiver's stress) and/or the victim's denial or apparent reluctance to acknowledge the situation.
The purpose of the assessment stage is to focus on the act itself. Is there reason to suspect abuse exists? What is the nature of the abuse? What has happened? What behaviour can be documented? What have been the consequences?
First tell a caller (client): "I am not a lawyer. I am a legal information counsellor. Everything we talk about today is confidential. I will not share this information with others unless you ask me to or give permission. There is no charge for our service."
If the report comes from the victim of abuse or from the abuser:
Establish what has happened and then take direction from the client as to further staff involvement. Document the information obtained from your interview in a case file. If appropriate, proceed to case management stage of protocol.
If the client is a person who appears confused, inconsistent in giving instruction, or displays difficulty in understanding information offered:
Determine whether there is an immediate danger or need for intervention, and discuss case with supervisor or supervising lawyer.
If the client lives with the abuser:
Offer flexibility in terms of telephone conversations, location of interview, etc. Assure the client that if you need to call back to the home and someone else answers, you'll identify yourself as the "volunteer centre" or whatever else is appropriate and non- threatening.
If the client is disabled (physically, mentally, in terms of language):
Acknowledge the special difficulties involved in giving information. Offer flexible arrangements. Communicate that extra time or unusual effort is part of the service we are funded to provide.
If the client is requesting service that is not possible or appropriate for you to provide, given your agency's mandate: Identify the appropriate body to whom the caller can be refer-red. Explain the other agency's service to the person and ask if the caller wishes you to call the other service. If he or she does, contact the appropriate agency or person, and note a date to follow up the referral.
If the elderly person is not ready to use a service:
Leave written information with that person describing where and how services may be obtained when the individual is ready to access them. Leave your agency information with the person in case he or she wants to contact you again.
If the client is a staff person of another service, a neighbour, friend or relative (someone other than the person subject to abuse or the abuser):
Share our philosophy of self-determination of the elderly. Tell the caller that we do not have a mandate to investigate or intervene. Explain that we act on the instructions of the elderly person and that our procedures reflect our philosophy, which is to return power and control to victims. Explain that we prefer a victim of abuse to be told about our services and given the option to contact us directly.
Do not enter into a case discussion if this would violate client confidentiality.
If the caller is seeking information or guidance on the best way to support or assist an abused person or the abuser: Offer that information unless your actions will trespass on the elderly person's rights or privacy and self-determination.
Offer an "entry role," i.e., check to be sure that the elderly person is receiving all entitlements, or provide information about low-cost housing. Often the person reporting abuse will become a valuable ally and support to an elderly person who has been in an abusive situation.
Complete the case record sheet, identifying the name of the senior (if available) and the name of the actual caller. If appropriate, proceed to the case management stage of protocol.
This stage involves identifying the range of options available to the client and taking instruction from the client.
Refer to the eligibility criteria before proceeding.
A community law office differs in many ways from other services that might come into contact with the elderly. We do not have to make decisions in the best interests of the client's health, family relationships, or even the protection of his or her assets. It is our role to ensure that our client has:
If the client has been subject to abuse:
Is that person capable? Assume capability unless the client has been certified as incapable or is subject to a Supreme Court Order of committeeship.
If the client has been declared incapable or is under the care of a committee:
Exercise discretion in determining whether or not to take instruction. The client may be entitled to representation to ensure basic civil liberties. Discuss with supervisor or supervising lawyer.
Instruction is to be taken only from the elderly person and not from another representative unless proof of extent of authority is available, documented and copied for the file.
Community health units promote the health of individuals and communities through a variety of preventive, protective and treatment strategies.
Courtesy of Vancouver Health Department Vancouver, British Columbia
Any staff person who is made aware of a possible situation of abuse of an elderly person will document the situation in writing. This documentation should include the following:
Also, the following questions are suggested and answers should be documented.
If the person resides in a licensed community care facility (CCF):
Contact the Director of CCF Licensing for further assessment and follow-up.
If the person resides in the community and is known to the Health Department:
Contact the primary worker by telephone, and forward intake documentation.
Primary worker checks the client's file for risk factors (history of abuse, mental status, caregiver's stress or deviance, drug/alcohol abuse, history of mental illness, etc.).
Primary worker obtains collateral information as appropriate, for example, contacts client's physician, referral source, service providers, etc.
Primary worker discusses intervention with supervisor, and if appropriate, MHO at Health Unit.
If the person being referred is not known to the Health Department:
If the elderly person meets eligibility criteria for Health Department programs, follow procedures listed below under Assessment.
If the elderly person is not eligible for Health Department programs, complete written documentation and submit to supervisor. The decision is then made whether to continue with assessment or, in consultation with MHO, and the Unit Director (or Clinics Administrator), the decision is made that the situation does not fall within the Vancouver Health Department's mandate, and,
Staff member conducts personal assessment to determine if abuse situation exists.
Suspected abuse unconfirmed.
Review the resources available for client and/or caregiver, give the date that you will keep in touch by visiting or phoning back, and terminate the interview.
If the primary worker determines that the client continues to be at risk, follow-up as required.
Complete documentation in report form and submit to supervisor.
Provide feedback to referral source, as appropriate.
Abuse confirmed:
If the client and/or caregiver refuses assistance and MHO has assessed the client and found the client incompetent to make an appropriate decision, then the MHO, in consultation with the client's physician or physician from the Mental Health Team, will certify the client incompetent under the Mental Health Act and arrange for committal to a hospital psychiatric unit or mental health facility for physical assessment, treatment and follow-up.
When physical abuse is evident and the elderly person is incompetent and at risk, the police have the authority to intervene and remove the abused person to a hospital for treatment. Should this happen, contact the Office of the Public Trustee to ensure protection of the client's property.
If client is competent to make decisions and refuses assistance, leave a list of resources available, including an emergency number, and terminate the interview.
If client/caregiver accepts assistance, identify and facilitate the use of appropriate resources. Resources may include those provided by the Department and for those provided in the community.
If there is evidence of physical abuse, the primary worker is advised to call the police (911) and report it.
Complete written documentation in report form and submit to supervisor.
Provide feedback to the referral source as appropriate.
[Adapted with permission from Robert Gordon. The Stages of Reform in Canadian Adult Guardianship Law (working title). Manuscript in progress 1994.]
The legislation varies widely, especially with the reform activity presently taking place across Canada. There are now roughly four models:
This model is found in Manitoba, Yukon and the Northwest Territories, although it will soon disappear in favour of new, "Second Wave" legislation. (Manitoba, for example, has just enacted "health care directives" legislation.) These jurisdictions still rely heavily on court-ordered guardianship/committeeship using legislation dating from the Victorian era, although it may have been modified by more recent amendments. No specific provision is made for intervention in abuse and neglect cases.
Mental health legislation provides for "statutory committeeship" (also known as "statutory guardianship") whereby a public trustee service assumes the management of a person's estate once he or she is admitted to the mental health facility. This was introduced in the 1960s and is often known as the "medical certification procedure." The options can be used quickly but intervention may require the use of bogus findings of mental incapability and other creative legal manoeuvres.
This model is characterized by its use of "recently" enacted adult protection legislation (which differs interprovincially). It has "back-up" mental incompetency legislation of the traditional kind (e.g., dating from the Victorian era) and mental health legislation that still provides for "statutory committeeship" (statutory guardianship). The worst excesses of statutory committeeship are softened by the use of enduring powers of attorney.
Both Alberta and Saskatchewan have enacted similar dependent adults legislation which are rooted in 1970s thinking around guardianship issues. This model was progressive for its time but is bypassed by the Second Wave Model. No specific provisions for intervention in abuse and neglect cases are made, but intervention is possible through guardianship orders. This model retains statutory committeeship/ guardianship and has enduring powers of attorney. Health care directives are now being closely considered.
This model is found in Quebec, Ontario and British Columbia (although legislation is not yet proclaimed in force in Ontario and British Columbia). These jurisdictions have undertaken comprehensive reviews and reconstructions of all their legislation affecting guardianship and substitute decision making. This has resulted in new approaches to:
Many other approaches have also changed, such as the place of legal and non-legal advocacy in these schemes. Ontario has created an advocacy commission, while British Columbia is taking a different approach.
Along with diverse approaches for defining competency and incompetency in the different jurisdictions, there are also numerous ways of measuring and responding to it. For example, the newer second wave schemes recognize that a person's decision-making incapability may be, in part, a function of the lack of supports. If support and assistance are provided (e.g., through volunteer advocates) guardianship may not be needed.
[Reprinted with permission from the Government of Newfoundland, Department of Health.]
The Canadian Charter of Rights and Freedoms enshrines the right of all Canadians to "life, liberty and security of person" (Charter of Rights and Freedoms, Minister of Supply and Services Canada, 1982). The Department of Health, in keeping with this right, has developed the following statements of principle and policy for use by all direct employees of the Department and agencies which are directly operated by the Department of Health.
The Department of Health recognizes:
The Department of Health acknowledges:
The Department of Health is committed to:
The Department of Health will endeavour, through its programs and services, to promote awareness regarding the impact of abuse on individuals, families and communities, and will develop mechanisms for prevention, identification and intervention to address this problem. This response will incorporate a multi-disciplinary approach and will involve collaboration with relevant government departments and community agencies. All divisions and agencies of the Department shall develop protocols related to responding to the abuse of persons.
The Common Room in a seniors' apartment complex is a place to socialize. It is also the place where the differences in the way that people socialize can become an issue.
A planning meeting is taking place, involving a committee chosen from prospective residents of a new seniors' housing co-op. The main item on the agenda is setting guidelines for the use and upkeep of the Common Room.
Anna - age 81, is a first generation Canadian of Polish descent. She has robust health, is an active member in her Catholic Church group, loves to cook for bazaars and sew for craft fairs. Anna dotes on her many nearby grandchildren, and frequently baby-sits them in her own home. She has always worked as a homemaker. Her husband has recently passed away and she is selling her home and moving into the co-op.
Jack - age 73, is a seventh generation Prince Edward Islander. He is still physically active. Jack loves to go for walks, read books, watch sports on television and play cards. He is presently living in a duplex with his wife, Lea. They are selling their home and moving into the co-op.
Lea - age 69, is also a native Prince Edward Islander. She is vigorous and active. At a young age Lea married Jack, raised five children and then worked in an office after her children were in school. She is a leader in the seniors movement, and helped organize a seniors' drop-in centre. She has recently seen how many inner-city seniors are isolated and marginalized and is preparing to take this on as a cause.
Martha - age 65, is a second generation Irish Canadian, who moved to Prince Edward Island 12 years ago. Martha raised her children as a single parent. She is recently retired. Martha has a network of friends who enjoy socializing, playing music and having potlucks - fun that doesn't cost money. She has never owned a home of her own.
Said - age 75, is a first generation Canadian from Lebanon. Said is a Muslim and is active in the multicultural community. He likes to play backgammon and discuss politics. However, his mobility is diminished because of a disability, so his friends visit him at home. He is a widower who is selling his home and moving into the co-op so he can be around other people more.
Discussion:
[Reprinted with permission from P.E.I. Association of Social Workers. Learning Today for a Better Tomorrow. Charlottetown: Tea Hill Press, 1991, pp. 12-14.]
Harold, 77, lives alone in the country with no means of transportation. His nearest neighbour appears every month at cheque time to buy groceries. There is never any money left over.
Jack, 82, has lived independently all his life. With no living relatives, he moves in with some new friends (a young couple) and pays for room and board. Shortly after he changes his will to include them, they refuse to allow Jack's closest friends to visit.
Alice, 80, is home from hospital with a terminal illness. She is pushed around, handled roughly by family members and referred to as "it."
Ada, 75, is physically disabled and has her unemployed daughter living with her. Her daughter's boyfriend touches her breasts and kisses her when the daughter is not at home.
Sarah, 84, is bedridden. She spends her time in the second-floor bedroom of her son's home. Her room is dirty, meal times are irregular, and her hearing aid has not been repaired.
Donald, 78, lives alone and is severely arthritic. His house is piled high with garbage which presents a health and fire hazard to his neighbours.
Mary, 64, lives alone and is confined to a wheelchair. She has adapted to her disability, but family members worry that she would be vulnerable if fire broke out in her house. They would like to see her in a long-term care facility, but Mary insists on staying at home.
Thomas is a 65-year-old widower with no functional disabilities and a close network of family and friends. He has the financial resources to maintain his home comfortably and operate a car. He is at little risk of being abused or neglected.
Maria is a 75-year-old married woman with severe functional and mental disabilities. She is living with a spouse who has a history of wife battering and an alcohol addiction. Maria is at high risk of being abused.
John is a 60-year-old, dynamic man, with friends and family who interact with him regularly. However, he has a soft spot for a nephew who solicits his financial support for his education. The nephew then asks John to supply capital to help him get started in business. John keeps giving, but tells no one because he doesn't want his nephew criticized. He uses up much of his savings.
Marjory was a harsh stepmother who, at 75, demands that her stepdaughter look after her. Her own son has abandoned her. The stepdaughter is single and has limited financial resources. However, she turns out to be a dutiful and kind caregiver.
Michael is 70 years old and has been caring for his wife Beth for seven years, ever since her condition began to deteriorate because of Alzheimer's disease. As her disease progressed, Michael moved from taking over tasks of daily living (shopping, handling finances, making appointments for Beth and driving her to them) to providing personal care such as dressing and feeding. Michael has become increasingly lonely and depressed as his wife's wandering has required his constant supervision. Beth has ceased to be the close companion he is accustomed to, reacting to his care with belligerence and aggression. Michael has found himself resenting her and becoming angry at her and at the situation.
Mary is a 70-year-old diabetic who lives in the country. Neighbours have called the public health nurse because Mary's husband always goes off with drinking friends on cheque day and is gone for a few days. Neighbours fear that Mary, who has no transportation, is not getting enough to eat. If this is so, Mary may not be able to control her diabetes. They also think that her husband is using up both their pensions during his outings.
Mr. MacAndrew has always handled all his own financial affairs. Recently, he made enquiries about a reverse mortgage, which would increase his living allowance while diminishing the equity on his house. Since then his two daughters, who oppose the plan, have taken turns accompanying Mr. MacAndrew to the bank. Mr. MacAndrew appears agitated by their presence.
Mrs. Wong is a 73-year-old woman who moved to Canada to live with relatives four years ago. Due to financial pressures, the entire family works, leaving Mrs. Wong by herself during the day. The family expects her to do housework in exchange for room and board. The older woman sees no one and never goes out. When the family goes on outings, they seldom take Mrs. Wong with them.
[A] man tied his disabled wife to a chair. The neighbours complained about this apparent barbaric treatment of his spouse. Eventually, she was removed from the home and taken to a nursing home much to her ... husband's objections. ... [T]he first time he went to visit his wife in the nursing home, he found her tied to a chair in much the same way he had done (Johnson, T.F. "Elder Mistreatment Identification Instruments: Finding Common Ground," Journal of Elder Abuse and Neglect, Vol. 1, 1989, p. 33-34).
Some professionals consider all forms of physical restraint abusive, and some institutions have banned restraints. Can caregivers still meet the ethical obligations to protect the older people if restraints are banned?
What responsibility do we have to put resources into finding alternatives, if the use of physical or chemical restraints is considered unethical?
Is the use of physical and chemical restraint an ethical practice in any situation?
Is the use of restraints a type of abuse?
Is there a need to educate staff and management in long-term care facilities on issues concerning restraint?
Samuel is a vibrant immigrant whose wife has been dead for three years. He lives alone, on limited resources, in an apartment in an ethnic neighbourhood. He has developed coping mechanisms to maintain his independence despite some health and memory problems. His nephew reports that he is losing weight and seems disoriented. The nephew feels Samuel is undernourished and is not paying close attention to his diabetes.
Samuel is taken to a hospital where his condition stabilizes. He is confused and disturbed by the hospital routine and finds it hard to communicate because he cannot speak English fluently. Samuel insists on returning home, claiming he is not a risk to anyone else. He does not, however, have the financial resources to pay for homemaker services.
While he is in the hospital, Samuel is assessed as incompetent to choose where to live and is placed in a long-term care facility. He becomes depressed and listless.
The complainant is a resident of a nursing home. Her ailments include severe back problems. She was used to writing letters to her old friends and relatives, most of whom lived far away. Because of her back condition, she wrote these letters sitting sideways at a high desk she had brought to the home, with her left arm resting on its surface to support her body. All was well until the home was redecorated. Then she was told she must give up her old desk because its well-worn look didn't match the new and uniform decor. In return, she was given a new but lower desk. From that time, her problems began. The lower height of the new desk made balancing difficult. In fact, she toppled over once and was badly bruised. She repeatedly asked for the return of her old desk, but all pleas were denied. She continued to experience discomfort when writing and felt vulnerable. Also, she thought the staff considered her complaints as whining, and this affected their attitudes toward her. So she contacted an advocacy association for help (As cited in Stones, Michael J. The Meaning and Measurement of Elder Abuse. St. John's: Milestones, 1994, p. 10).
[Reproduced with permission from Government of Nova Scotia, Adult Protection Services]
To illustrate an adult protection case involving court intervention under section 9 of the Adult Protection Act.
Mrs. K. is a 66-year-old female who was referred by a neighbour who was concerned that Mrs. K. who lived alone was neglecting her own care.
Visible signs of neglect:
Personal hygiene (i.e., body odour, matted hair)
- Dirty clothing
- Smell of rotten garbage
- Little edible food in the house
- Possible malnutrition
Mental/physical limitations to providing adequate care:
Disoriented to time, place or person.
Unsteady on her feet and walks with a cane and by holding on to furniture.
Social isolation:
During the home assessment, the worker and the daughter reviewed service options with Mrs. K. She reluctantly agreed to in-home services but was adamant that she would not leave her home.
Homemaker services were initiated on a 7 hours per day, 7 day per week basis. In addition, Mrs. K.'s daughter agreed to visit each night after work and on the weekends.
The action plan continued for two months. The worker received information from the homemaker staff and daughter that Mrs. K.'s mental state was deteriorating. In addition, her physical state was declining to the point that she required constant supervision and assistance with activities of daily living.
The worker met with the daughter, homemaker staff and Mrs. K. to review service options. The family doctor was also contacted and he indicated that Mrs. K.'s mental and physical condition had deteriorated and she required placement in a home for special care. He also stated that Mrs. K.'s judgment was impaired and she did not realize the implications of remaining at home.
Mrs. K. continued to refuse the idea of placement. Her daughter suggested that Mrs. K. could stay at the daughter's home, with the existing homemaker service through the day, until a court hearing was held.
The worker made application to family court under section 9 of the Adult Protection Act and Mrs. K. was subsequently placed in a home for special care.
[Reproduced with permission from Government of Nova Scotia, Adult Protection Services]
Mrs. Ruth Smith, a 79-year-old widow was referred to Adult Protection Services by a social worker at the local hospital. The allegations were mental cruelty and neglect by her son, Mr. Joe Smith, with whom she lived.
Mrs. Smith had been admitted to hospital with a diagnosis of congestive heart failure and elevated blood sugar. In addition to diabetes and heart problems, Mrs. Smith's limited mobility due to circulatory problems and poor eyesight prevented her from preparing meals. Although Mrs. Smith could administer her daily insulin, she required assistance to ensure that she received other required medications.
The hospital social worker had interviewed both Mrs. Smith and her son before Mrs. Smith's discharge from hospital. The social worker voiced the following concerns to the Adult Protection worker.
1. Mr. Smith was observed to be intoxicated when visiting his mother and was overheard yelling at his mother on a number of occasions.
2. Mr. Smith would not agree to a referral for homemaker service for his mother.
3. Mrs. Smith had admitted to a continual verbal abuse and occasional slaps by her son.
4. Mrs. Smith agreed to have help at home but said she was afraid to go against her son's wishes.
The hospital social worker was requesting an assessment by the Adult Protection worker to determine whether Mrs. Smith was receiving adequate care at home.
Collateral information obtained by the Adult Protection Worker from the family and V.O.N. indicated the following.
1. The doctor and the V.O.N. had observed the son's drinking problem and had concerns about his ability, when drinking, to provide a proper diet and dispense medications.
2. Mrs. Smith had told both the doctor and the V.O.N. that her son's verbal abuse was very upsetting to her and that she was afraid to do anything about the situation.
3. The doctor had experienced Mr. Smith yelling at his mother and felt that this was having an effect on Mrs. Smith's diabetes.
The Adult Protection worker interviewed Mrs. Smith alone, Mr. Smith alone and Mrs. and Mr. Smith together. These interviews were conducted during the day and during the evening in Mrs. Smith's home.
The information obtained during these sessions, along with the worker's observation of Mr. Smith's drinking, verbal abuse, inappropriate meal preparation and medication management confirmed most of the information which had been obtained from the hospital social worker, the family physician and the V.O.N.
Mr. Smith admitted that he occasionally yelled at his mother because she got on his nerves but he stated that he had never slapped her.
Mrs. Smith told the worker her son was constantly yelling at her when he drank and had slapped her on two occasions in the last year.
Mrs. Smith was assessed by Co-ordinated Home Care and her family doctor as requiring six hours of homemaker service on a seven-day-per-week basis.
Mr. Smith reluctantly agreed to having this service provided to his mother and the homemaker service was implemented. Mr. Smith also agreed to a referral on his behalf to the Drug Dependency Commission.
Over a period of two months, the Adult Protection worker received calls on a weekly basis from the homemaker agency indicating that Mr. Smith had cancelled the service. Each time a call was received, the worker visited the Smith home to assess Mrs. Smith's condition and to reinforce with Mr. Smith the need for service for his mother.
During the last week of this two-month period, both the V.O.N. and the family doctor indicated that Mrs. Smith's health was deteriorating as a result of the constant turmoil in the home. In addition, the Adult Protection worker noted that Mr. Smith's verbal abuse was increasing, and he had not followed up on his appointments with Drug Dependency.
The Adult Protection worker met with Mrs. Smith to review her options for change. Mrs. Smith told the worker that she could no longer deal with her son's abusive behaviour but that she needed help to improve her situation. She agreed to the option of court intervention on the basis that she needed help but could not act on her own due to her fear of her son.
An application to Family Court under section 9 of the Adult Protection Act was initiated.
A court hearing was held within 12 days of the application.
On the basis of the information presented by the Adult Protection worker, the family doctor, the V.O.N., the hospital social worker, Mrs. Smith and Mr. Smith, the Family Court judge issued the following orders.
1. Mrs. Smith is found to be an adult in need of protection pursuant to section 3(b)(ii) of the Adult Protection Act.
- Mrs. Smith is not receiving adequate care and attention.
- Mrs. Smith is not capable of caring adequately for herself because of a physical disability.
- Mrs. Smith is unable to make provision for her adequate care and attention.
2. Pursuant to section 9(3) of the Act, Mrs. Smith is found to be refusing assistance because she is under duress.
3. Pursuant to section (3)(c) of the Act, the Minister is authorized to provide Mrs. Smith with services. The service plan presented in court involved:
4. Pursuant to section (9)(3)(d) of the Act, a protective intervention order was granted against Mr. Joe Smith:
- requiring Mr. Joe Smith to leave his mother's home;
- requiring that Mr. Joe Smith visit his mother only with her consent and during the time that homemaker staff are present.
- stating that if Mr. Joe Smith visits his mother without having her consent and without homemaker staff present or if he behaves in an abusive manner during the visit, he will be in breach of the protective intervention order and subject to prosecution under section 17 of the Adult Protection Act.
Orders under this Act are in effect for six months and then a court appearance is required to renew, vary or terminate.
The above-named orders were renewed after six months. Although Mrs. Smith was coping well in her home with services, Mr. Smith was still seeing a drug dependency counsellor and there were still concerns expressed over his ability to move back with his mother as a caregiver.
This case is up for renewal next month. Mr. Smith has stopped drinking and is attending Alcoholics Anonymous. Reports from the homemaker agency and the Adult Protection worker indicate that he has been following the conditions placed on the protective intervention order, and he wants to return to his mother's home. In addition, Mrs. Smith wishes to have her son at home but not as the primary caregiver. The recommendation to the Court will be that Mr. Smith return home, on a trial basis, with services still being provided to his mother by the homemaker agency.
We are hoping that this will work out and the orders can be terminated over the next six months.
[Reprinted with permission from the Government of Nova Scotia, Adult Protection Services]
To illustrate an adult protection case involving court intervention under section 10(1) of the Adult Protection Act.
From the referral source: Mrs. S. is a 75-year-old lady who was referred to Adult Protection Services May 16 at 2:00 p.m. by her nephew, Mr. G. He had apparently visited his aunt that morning and voiced the following concerns.
Mr. G. had attempted to contact the family physician that morning but he was unavailable. Mrs. S. was refusing to go see him or to go to the hospital to have her leg treated.
From the family doctor: The worker contacted the family physician who stated that he had seen Mrs. S. approximately three weeks ago after she had fallen in her apartment. He indicated that he was concerned for her safety at that time and suggested that she obtain service in her home to help with the meals and medication management. Apparently, Mrs. S. refused to even consider the need for any service. The doctor further stated that he felt Mrs. S.'s judgment was impaired as she did not seem to grasp the risk to her safety. In his opinion, the ulcers required immediate medical attention and he recommended that she be taken to the emergency department as soon as possible.
The worker accompanied by the nephew visited Mrs. S. at 3:30 p.m. and observed the following:
Short term: The worker judged the situation to be high risk. Consequently, Mrs. S. was removed via ambulance from her apartment to the emergency department of the local hospital. The authority for this removal was under section 10(1) of the Adult Protection Act.
Long term: Following treatment and stabilization in hospital, Mrs. S. may be able to return to her apartment with appropriate in-home services.
Mrs. S. remained in hospital for two weeks. As a result of proper medication management, she was no longer confused and the ulcers on her leg were healing. Mrs. S. agreed to homemaker V.O.N. service and was discharged to her home. The adult protection order on Mrs. S. was terminated as she was no longer at risk and was accepting services.
Mary is a widow living in her own home. She fell on an icy sidewalk and was admitted to hospital with a broken hip. Mary's nephew agreed to manage her financial affairs while she was in the hospital, and was granted general power of attorney. Mary had complications and developed pneumonia which extended her hospital stay. For a period of time, she was too in to pay much attention to her affairs.
When she recovered and prepared to move back home, she discovered that her nephew had put her house up for sale. He claimed that he felt that she would not be able to return to it. The house had not yet been sold, but Mary did find that many of her belongings were gone.
When Mary attempted to cancel the power of attorney, the nephew threatened to have her declared incompetent. The lawyer who drew up the power of attorney supported the nephew. Mary's sister is still alive and Mary does not want to hurt her by causing too much trouble for her son.
The median age of Canadians has been getting higher. In 1992, the median age of Canadians was 33.8 years, compared with 23.9 years in 1921.
In 1991, approximately 3.2 million Canadians were over the age of 65.
Less than 9% of older Canadians live in long-term institutions such as nursing homes, personal care homes and old age homes.
About 85% of those 65 years and over have at least one chronic condition, but many of these limitations do not affect their ability to function independently.
Only 38% of all older Canadians suffer from functional disabilities.
In Canada, at least 4% of older adults have reported that they have been mistreated.
Predictions are that by the time the baby boomers start leaving the ranks of the employed, business, labour and government will be looking for ways to keep older workers on the job, and to bring retirees back.
Over the last few decades job shortages, retirement benefits and negative stereotypes have led older adults to accept mandatory retirement or to choose early retirement opportunities.
From 1981 to 1991, labour force participation among men 65 to 69 decreased from 21.9% to 17.6%. For women of the same age, it declined from 2.5% to 1.7%.
Seniors as a group are not homogeneous. The differences among them in health, marital status, housing, income and ethnicity are as great as they are among younger Canadians. The living situations of older women often differ considerably from men of the same age. As Canadians live longer, this diversity will continue to grow.
The designation of "65 and over" for seniors is becoming increasingly arbitrary. Seniors, like other Canadians, are of different generations, each with their own history of social experiences. Some, for example, have experienced World War 1; others' memories do not pre-date the depression.
Abuse is any action by someone in a position of trust which causes harm to an older person.
Neglect is any in action, either intended or unintended, by someone in a position of trust which causes harm to an older person.
Types of Abuse and Neglect
Physical abuse
Psychological or emotional abuse
Financial abuse
- an older adult is surprised by an overdrawn or lower-than-expected bank balance
- unusual transactions conducted on behalf of an older person
Sexual abuse
Medication abuse
Denial of Civil/Human Rights
Neglect/Self-Neglect
Attitudes
Attitudes are feelings or emotions about a fact or state. Attitudes towards abuse and neglect of older adults include
Beliefs
Beliefs are opinions or convictions about some reality. Some false beliefs about abuse and neglect of older adults include
Additional barriers to identification and response for staff in an institutional setting include
In essence, ethics is a form of reasoning. It is a reflective process that attempts to answer the basic question: "What should I Do in This situation, All things considered?" It is important to emphasize that ethics involves reasoning not just for its own sake, as we might theorize, say, about the origin of the Universe. The domain of ethics is the domain of action; moreover, action that is concerned directly with our own life or other people's lives.
Mental competency refers to the ability to understand the information involved in making a decision and the ability to understand the consequences of that decision. The older adult may not appear to make the "best decision," but that does not mean that he or she is incompetent.
Incompetency can be limited to specific areas, such as financial matters or making medical decisions. Medical opinion is required to determine an individual's level of competence. A decision of incompetence is reversible when a persons condition improves.
The assumption that an individual is competent unless proven otherwise is enshrined in legislation. In all jurisdictions, the burden of proof is on those who wish to have an individual declared incompetent or incapable.
Ensure:
Physical assault
Financial abuse
Neglect
Mental cruelty
Principle 1
All adults have the right to autonomy and self-determination, and the right to enjoy the fundamental freedoms prescribed in the Canadian Charter of Rights and Freedoms.
Principle 2
All adults are entitled to receive the most effective, least intrusive and least stigmatizing form of assistance.
Principle 3
The use of protective care, court procedures and court orders should only occur as an absolute last resort and only after the provision of supports and assistance has been either attempted or carefully considered.
Each province and territory has methods of conferring guardianship. For example, in the Atlantic provinces, Prince Edward Island, sets criteria for guardianship in the Mental Health Act. The Nova Scotia Public Trustee Act provides for guardianship of physically disabled adults. Newfoundland uses the Mentally Disabled Persons' Estate Act as a means of protecting property, and New Brunswick has enacted the Infirm Persons Act, which also extends to older adults not necessarily declared incompetent.
A power of attorney is a legal document in which a mentally competent individual designates another person to carry out certain transactions or make decisions while he or she is temporarily indisposed as a result of injury, physical illness or lengthy periods of international travel. The older adult can limit the power of attorney to certain tasks, such as selling the house or paying bills or it can be extended to cover all financial matters. An adult can also name joint powers of attorney. These power of attorney provisions can be cancelled at any time and are invalid if the person becomes incompetent.
Legislation in Nova Scotia, New Brunswick, Manitoba, Ontario, the Northwest Territories and Yukon generally affirms a mental health patient's qualified right to refuse medical treatment if the person is considered competent. If a patient is deemed not competent to give or withhold consent to treatment, such decisions are to be made by a substitute decision maker.
Advocacy is the vigorous and systematic representation of the views and special needs of older people to those in authority. Advocacy affirms the dignity and rights of people who are in danger of being devalued, ignored or harmed by the structures and systems of society.
Individual seniors, families, non-profit organizations, private enterprise and the public sector depend on one another and are responsible to one another. Certainly, the ability of any partner to fulfil its role with respect to seniors' independence and autonomy depends upon the support of the others. A concerted and collaborative effort is required to maintain the independence and autonomy of seniors in the community.
[Adapted with permission from a survey for
"Independent Living for the Elderly, Waterloo Region"]
Please answer these questions if you are an older adult or personally know an older adult in your community who has special needs. You do not need to identify yourself:
Living Arrangement Age
alone 60-65
spouse 65-70
companion 70-75
family 75-80
other 80+
Type of Living Quarters
house apartment seniors' apartment nursing home other
Sex
M
F
Income
comfortable - struggling - in poverty
Major Need (explain)
Housing
Financial
Meals
Transportation
Shopping
Medical
Dental
Companionship
Other
What did you want to get out of this workshop?
Was this session useful?
What did you dislike?
What is the most useful thing you learned?
What would you like to see changed?
Would you recommend this workshop to others?
Complete this evaluation form each time a workshop is given. Participants and settings change, so this form will let you know what is most/least useful for different groups.
Describe the workshop participants?
Where did the workshop take place?
How long was the workshop?
Which modules were the most useful?
For this audience, what information could have been added?
What information was not useful to this audience?
What action resulted from the workshop?
Please return this evaluation form to the Mental Health Division, Health Canada, Jeanne Mance Building, Ottawa, Ontario, KIA 1B4.
1. How have you used the resource and training kit?
2. What was most useful about the kit?
3. What was least useful about the kit?
4. Who have you shared the kit with and in what context?
5. What recommendations would you make for the development of additional resource material?
6. What areas still need to be addressed in the prevention of abuse and neglect of older adults?
7. Additional comments/suggestions.
The following resources are available free of charge or at minimal cost to supplement material in the kit. Other sources are referenced in the endnotes.
National Film Board - videos may be borrowed through regional offices. For further information, contact: National Film Board of Canada, P.O. Box 6100, Montreal, Quebec H3C 3H5.
P.E.I. Association of Social Workers, Elders Ourselves, video and guide P.O. Box 1888, Charlottetown, P.E.I. CIA 7N5
National Clearinghouse on Family violence, Health Canada, Family Violence Audio-Visual Source Guide, Ottawa, Ontario, KIA 1B5.
Mental Health Division, Health Canada, Ottawa, Ontario, KIA 1B4. National Clearinghouse on Family Violence, Health Canada, Ottawa, Ontario, KIA 1B5. National Advisory Council on Aging, Ottawa, Ontario, K1A 0K9.
Health Service Systems Division
Health Services Directorate
Health Canada
Women's Secretariat
Government of PEI
Adult Protection
Department of Community Services
Nova Scotia
Summerside Health Centre Systems
Division of Community and
Residential Services
Department of Health and Social
Services, P.E.I.
Women's Policy Office
Government of Newfoundland and Labrador
Mental Health Division
Health Services Directorate
Health Canada
Seniors' Secretariat
Government of Nova Scotia
Adult Protection Program
Division of Homecare Support
Department of Health and
Social Services, P.E.I.
Office for Seniors
Department of Health and
Community Services
Government of New Brunswick
Mental Health Division
Health Services Directorate
Health Canada
Basu, Ranjy. Elder Abuse: A Practical Handbook for Service Providers. Toronto: Ontario Association of Professional Social Workers. April 1992.
Bentley, Sandra. "Abuse/Neglect Protocol." Charlottetown: P.E.I. Department of Health and Social Services Division of Home Care and Support. 1987.
Bookin, Deborah & Ruth Dunkle. "Elder Abuse: Issues for the Practitioners." Social CaseworL The Journal of Contemporary Social Work, Vol. 66, No. 1, January 1985, p. 3-12.
British Columbia InterMinistry Committee on Elder Abuse and Continuing Care Division, Ministry of Health and Ministry Responsible for Seniors. Principles, Procedures and Protocols for Elder Abuse. Victoria: Ministry of Health & Ministry Responsible for Seniors. February 1992.
Brower, H. T. "Physical Restraints: A Potential Form of Abuse." Journal of Elder Abuse and Neglect, Vol. 4, No. 4, 1992, pp. 47-58.
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