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Restraining the Elderly--Japanese do it, Europeans don’t, Americans try not to, How about Us?
Anna Liachenko, BSc, MSc
Managing Editor,
Geriatrics & Aging
Ensuring the safety of nursing home residents is a high priority for both families and health care personnel. To this end, various types of restraints have traditionally been used to protect residents from falls and injuries. Ironically, there is little documented evidence that restraints either prevent falls, or decrease the risk of injury from falls. In fact, studies demonstrate that restraints may precipitate or heighten this risk. In the United States, the Omnibus Budget Reconciliation Act of 1987 (OBRA-87) was passed in response to a host of consumer complaints in addition to state and federal reports criticizing nursing home quality. As part of the reforms, a restriction has been placed on the use of restraints. In the ensuing thirteen years there has been a 50% reduction in the use of restraints and, interestingly, also a significant reduction in the incidence of fall-related injuries. It is not clear whether Canadian nursing homes overuse restraints. Progressive institutions are currently moving towards reducing the use of restraining measures. It is crucial that physicians take into consideration the potential hazards of restraints when evaluating the management of an elderly patient.
Restraints have traditionally been categorized as either chemical or physical.
Elder Abuse--What You Should Know About What To Do
Tracey Tremayne-Lloyd
and Lonny J. Rosen
Tremayne-Lloyd Partners
Toronto, Ontario
Elder abuse is an unfortunate and undiscussed phenomenon in our society, yet it is one that many physicians will encounter in the treatment of their elderly patients. Although there is little agreement on the definition of elder abuse, it can generally be defined as 'any act of commission or omission that results in harm to an elderly person.'1 The types of harm suffered by elderly patients generally include physical, psychological, and financial abuse as well as neglect. Various studies conducted throughout North America have reported the incidence of elder abuse to be anywhere from 1%-10%. Since elder abuse is such a prevalent problem, it is critical for physicians to be aware of their statutory and professional reporting obligations.
Statutory Reporting Obligation
At present, there is no federal statutory obligation on the part of physicians across Canada to report elder abuse. Such obligations are set by provincial governments, and each of the provinces of Newfoundland, New Brunswick, Nova Scotia and Prince Edward Island have enacted some type of adult protection legislation. These laws impose on all persons the obligation to report a situation where a person is suffering from abuse or is otherwise in need of protection. The legislation in these provinces includes not only abuse of the elderly, but also usually covers all adults over the age of 16 or 18 years, who are in need of protection.
More than just the catch-phrase of the day, 'Living Wills' appeared to be the answer for increasing patient control in end-of-life decisions, and a much sought-after solution for an aging population (but one that is increasingly sophisticated about treatment options). The issue of Living Wills was explored in the May/June 1998 edition of Geriatrics and Aging in an article entitled 'Living Wills Ease Patient's Fear' by Lawrence J. Papoff (please see our web site www.geriatricsandaging.com for this article). Recent research has demonstrated that the Living Will is an instrument well-liked by physicians and patients for its capacity to empower patients with independence when facing a life-threatening condition, but it is still surprisingly under-used. It is important for physicians treating geriatric patients to be aware of the extent to which Living Wills can be incorporated into their practice, and to consider their role in educating patients about the issue.
A Living Will is nothing more than a written document that speaks for your patient after he or she becomes incapable of making or communicating his or her own health care decisions.
Physician Assisted Suicide--Past, Present and Future
Dr. Michael J. Taylor
The following article attempts to add insight into the complex and difficult issue of physician assisted suicide by approaching it from a broad perspective. The article will begin with a brief and informal historical survey of attitudes toward physician assisted suicide. It will then address the arguments both for and against this issue, and conclude with an examination of some of the evidence that is available to support concerns of those on both sides of the debate. Included in the article are some inferences as to the direction debates about physician assisted suicide might take in the future. Though terms such as euthanasia and physician assisted suicide are often used to denote different entities both by the lay public and within the medical literature, for the purposes of this article, the term physician assisted suicide is used to describe the active involvement of a physician in ending the life of a patient at the patients specific request (i.e. through the prescription or administration of lethal medications). The act of ending the life of a patient without his or her specific request (i.e. "mercy killing"), and the decision to forgo life sustaining treatment (including the use of ventilators, dialysis or feeding tubes) are not included within the definition of physician assisted suicide as discussed in this article.
Group of Seniors Use Drama to Educate about Elder Abuse
Olya Lechky
A group of volunteers at the Bernard Betel Centre for Creative Living in Toronto have found a unique way to bring elder abuse out into the open.
Like spousal and child abuse, elder abuse is still shrouded in secrecy, denial and shame, says Sheila Zane, co-ordinator of a 15-member drama group that performs plays depicting various aspects of elder abuse. "Basically we do education through drama," says Zane. "Drama is the best vehicle to educate on sensitive and painful issues. Many seniors would not be interested in hearing a lecture on elder abuse, but many are interested in exploring the issue by seeing a play-acted out by seniors. We approach elder abuse by getting in through the back door."
The Bernard Betel Centre provides social activities, recreation, education, meals, counseling and referrals to its members, whose average age is 70. The Awareness Project on Abuse of the Elderly Committee promotes education on elder abuse by means of workshops, information, referrals and play presentations in the community. Originally, the committee focussed on educating the public through the media, lectures and speaking engagements. The idea of going out into the community to educate on elder abuse through drama is a relatively recent addition to the committee's educational efforts.
As Canadians age, they are becoming concerned with the infirmities that aging can bring. And one of those infirmities is Alzheimer's Disease (AD). It is the specter of the Alzheimer patient, unable to fend for herself or himself, suffering a prolonged period of dying, incapable of communicating a decision to end life-sustaining treatment, that has popularized the use of the living will.
Geriatrician Dr. Barbara Clive says she sees an increasing number of living wills in use among her patients, one-third of whom suffer from some form of dementia, most often AD. More and more patients are filling out the paperwork and having discussions with their families about end of life decisions.
A living will, or advance directive, is a written document that contains the will maker's wishes regarding medical treatment and personal care. Taking effect only when the maker is incapable of understanding and appreciating what medical treatment or care is required, it instructs a representative, called an attorney, to decide what treatment should be used, and when it should be terminated. The document may also give decision-making ability to a number of attorneys and provide for resolution of disagreements among them.
The Bernard Betel Centre provides social activities, recreation, education, meals, counseling and referrals to its members, whose average age is 70. The Awareness Project on Abuse of the Elderly Committee promotes education on elder abuse by means of workshops, information, referrals and play presentations in the community. Originally, the committee focussed on educating the public through the media, lectures and speaking engagements. The idea of going out into the community to educate on elder abuse through drama is a relatively recent addition to the committee's educational efforts.