Introduction to gerontological planning and services with a special expertise

in the needs of older adults.

nursing  Gerontological Rehabilitation Nursing –
combines expertise in gerontological nursing
 GERIATRICIAN-A geriatrician is a primary
with rehabilitation concepts and practice.
care doctor who specializes in treating older
 Gerontological Nursing- discipline of nursing
adults. They may provide integrative care,
and the scope of nursing practice. It involves
diagnose a variety of conditions, and help you
nurses advocating for the health of older
maintain a high quality of life.
persons at all levels of prevention.
 Gerontologists are professionals who study
 Geriatric Rehabilitation (GR) aims to restore
aging and promote well-being among older
function or enhance residual functional
adults
capacity and improve the quality of life in older
 They include researchers and
people, particularly those with disabling
practitioners in various fields such as
impairments and/or frailty. Current
biology, nursing, medicine,
rehabilitation practice focuses on function and
criminology, dentistry, social work,
well-being, not exclusively on disease.
physical and occupational therapy,
psychology, psychiatry, sociology, Roles of the gerontological nurse
economics, political science, a) Provider of care
architecture, geography, pharmacy, b) Teacher
public health, housing, and c) Manager
anthropology d) Advocate
 Gerontologists have, at minimum, a e) Research consumer
master’s degree in gerontology or a
related field Certification
 Gerontology - is the study of aging and/or the
aged. This includes the biopsychosocial  To provide competent, current care to elders,
aspects of aging. nurses need to have gerontological nursing
 is concerned with the social, content in their basic undergraduate nursing
psychological, and biological aspects curricula and are encouraged to become
of aging. certified in gerontological nursing.
 Geriatrics – is often used as a geriatric term  Nurse certification is a formal process by
relating to the aged, but specifically refers to which a certifying agency validates a nurse
medical care of the aged. knowledge, skills, and competencies through a
written examination in a specialty area of
- is the study of disease in the elderly. practice.
 Social gerontology – is concerned mainly with 2 levels of certification
the social aspects of aging versus the 1. Generalist Certification – has completed a
biological or psychological. basic entry – level program in nursing which
 Geropsychology – is a branch of psychology can be a diploma in nursing, or an associate or
concerned with helping older persons and their bachelor of science degree in nursing.
families maintain wellbeing, overcome 2. Advance Certification (Clinical Specialist in
problems and achieve maximum potential Gerontology Nursing & Gerontological Nurse
during later life. Practitioner) - the advanced practice role
 Geropharmacology – is the study of encompasses education, consultation,
pharmacology as it related to older adults. research, case management, administration,
and advocacy in the care of older adults.
Social aspects of aging
Social aspects of aging include: Core Elements of evidence-
 Changes in a person’s roles and relationships based gerontological nursing
within their networks of relatives and friends.
 Impact of social factors such as social support, practice
isolation, and cultural influences on mental
and physical health outcomes. Scopes and Standards of practice
 Major life changes, fear of the future, memory  The scope of nursing practice is defined by
and learning, loss of independence, grief and state regulation, but it also influences by the
loss, ageism, and discrimination are unique needs of the population being served in
psychological and social impacts of aging. a given setting. The needs of older adults are
 Financial gerontology – is another emerging complex and multifaceted,( many sides) and
subfield that combines knowledge of financial
 the focus of nursing care depends on the 6. Assess older adults’ living environment with
setting in which the nurse practices. special awareness of the functional, physical,
 Gerontological nursing practiced in cognitive, psychological and social changes
accordance with standards developed by the common in old age.
profession of nursing. In 2001, the ANA
Division of Gerontological Nursing Practice
developed the second edition of the “Scope of  Assessment tools include: Get-Up-and-Go
Gerontological Nursing Practice”, in (timed and modified), 30-Second Chair Stand,
collaboration with the National Gerontological 4-Stage Balance tests, and Functional Reach.
Association, the National Association of
Directors of Nursing Administrators in Long 7. Analyze the effectiveness of community
Term Care, and the National Conference of resources in assisting older adults and their
Gerontological Nurse Practitioners. families to retain personal goals, maximize
 Standards are provided both for clinical care function, maintain independence, and live in
and for the professional role of the nurse. the least restrictive environment.
 These standards include assessment, 8. Assess family knowledge of skills necessary to
diagnosis, outcome identification, planning, deliver care to older adults.
implementation and evaluation. The standards 9. Adapt technical skills to meet the functional,
of professional gerontological nursing physical, cognitive, psychological, social and
performance include quality of care, endurance capacities of older adults.
performance appraisals, education, collegiality, 10. Individualize care and prevent morbidity and
ethics, collaboration, and research utilization. mortality associated with the use of physical
 Students should note that these are the basic and chemical restraints in older adults.
standards for professional nursing, but they 11. Prevent or reduce common risk factors that
are applied to the care of adults. contribute to functional decline, impaired
 Ethical issues abound in the care of older quality of life and excess disability in older
adults who present with psychiatric symptoms adults.
and syndromes (1). These issues range from 12. Establish and follow standards of care to
questions of capacity (Is the patient able to recognize and report elder mistreatment.
provide informed consent for treatment? Is the
patient capable of refusing treatment? If the  The highest strength of evidence for an
patient cannot consent, who can or should increased risk in functional status decline was
provide surrogate consent?) to ethical found for (alphabetical order) cognitive
implications of concerns about the patient’s impairment, depression, disease burden
safety or well-being (Is the patient safe to live (comorbidity), increased and decreased body
at home alone? Is the patient at risk of mass index, lower extremity functional
exploitation or abuse? Can the patient limitation, low frequency of social contacts, low
continue to drive safely?), to difficult questions level of physical.
about goals of care among frail older adults.  It is of paramount importance that standards of
care are monitored, especially for older
Core competencies persons who live in long term care facilities
Competencies Necessary for Nurses to Provide High –
Quality Care to Older Adults and their Families. 13. Apply evidence- based standards to screen,
immunize, and promote healthy activities in
1. Recognize one’s own and other’s attitudes, older adults.
values, and expectations about aging and their 14. Recognize and manage geriatric syndromes
impact on care of older adults and their common to older adults.
families. 15. Recognize the complex interaction of acute
2. Adopt the concept of individualized care as the and chronic co-morbid conditions common to
standard of practice with older adults. older adults.
3. Communicate effectively, respectfully and
compassionately with older adults and their  The most common geriatric syndromes
families. affecting older patients include falls, urinary
4. Recognize that sensation and perception in incontinence or overactive bladder, urinary
older adults are mediated by functional, tract infection, sleep problems, cognitive
physical, cognitive, psychological and social function problems such as delirium and
changes common in old age. dementia, and osteoporosis.
5. Incorporate into daily practice valid and  Geriatric syndromes include a number of
reliable tools to assess the functional, conditions typical of, if not specific to, aging,
physical, cognitive, psychological, and spiritual such as dementia, depression, delirium,
status of older adults. incontinence, vertigo, falls,
 The most common comorbid conditions that  What are some barriers to function
occur in elderly people include heart disease, independence in the older population?
hypertension, respiratory disease, - Barriers to independence include not so
cerebrovascular disease, diabetes, joint much age itself, but the ill health, frailty,
disease, sensory impairment, and mental increased need for medical attention,
health problems. handicaps, and difficulties with the
16. Use technology to enhance older adults’ activities of daily living that are more likely
function, independence, and safety. to arise with advancing age. Another
17. Facilitate communication as older adults significant barrier can be lack of money.
transition across and between home, hospital  Societal aging can affect economic growth,
and nursing home, with a particular focus on patterns of work and retirement, the way that
the use of technology. families function, the ability of governments
18. Assist older adults, families and caregivers to and communities to provide adequate
understand and balance “everyday” autonomy resources for older adults, and the prevalence
and safety decisions. of chronic disease and disability

 Interactive technologies, such as voice 25. Recognize the benefits of interdisciplinary

assistants, interactive robots, and artificial team participation in care of older adults.
intelligence-based interaction tools, have been 26. Evaluate the utility of complementary and
shown to effectively meet the social and integrative health care practices on health
emotional needs of older adults (Sidner, 2015; promotion and symptom management for
Ostrowski older adults.
27. Facilitate older adults’ active participation in all
19. Apply Ethical and Legal principles to the aspects of their own health care.
complex issues that arise in care of older
adults.  The multidisciplinary team approach plays an
20. Appreciate the influence of attitudes, roles, increasingly important role in the management
language, culture, race, religion, gender, and and care of elderly patients, providing support
lifestyle on how families and assistive to patients and families and helping them
personnel provide long – term care to older adapt to illness and treatment plans – it offers
adults. psychosocial counseling, patient and family
21. Evaluate differing international models of education, discharge planning and post
geriatric care. hospital care planning.

 What is the comprehensive geriatric Here are some advantages of interdisciplinary medical
assessment model? teams both to patients and healthcare professionals:
- CGA is based on the premise that a  Improves patient care and results. ...
systematic evaluation of frail, older  Minimizes errors. ...
persons by a team of health professionals  Enables faster treatment. ...
may identify a variety of treatable medical  Improves efficiency. ...
and social problems and lead to better  Boosts morale. ...
health outcomes.  Ensures consistency. ...
 What are the ethical considerations working  A patient-focused approach. ...
with older adults?  A clear aim.
 There are multiple areas in which ethical
issues can emerge, including complex family 28. Involve, educate and when appropriate,
dynamics, addressing end-of-life wishes, supervise family, friends and assistive
preserving dignity and respect, promoting personnel in implementing best practices for
independence, and keeping the individual older adults.
safe. Various factors can make older adults 29. Ensure quality of care commensurate with
vulnerable to abuse, neglect and ill intent older adults’ vulnerability and frequency and
intensity of care needs.
22. Analyze the impact of an aging society on the 30. Promote the desirability of quality end – of –
health care system. life care for older adults, including pain and
23. Evaluate the influence of payer systems on symptom management, as essential desirable,
access, availability, and affordability of health and integral components of nursing practice.
care for older adults.
24. Contrast the opportunities and constraints of a Principles of Gerontological
supportive living arrangement on the function
and independence of older adults and on their Nursing Practice
families.  Aging is a natural process.
 Various factors influence the aging process.
  Nursing of the elderly requires unique The Code
information and skills.
 There are common needs shared by the supports a person's right to personal choice, dignity
elderly and all ages. and respect. promotes kind, honest and respectful
 Gerontological Nursing’s goal is to promote behaviour. keeps people receiving aged care safe from
optimum levels of physical, psychological, harm.
social and spiritual health.  How to improve gerontological nursing
practice
The basic needs include financial security,
personal security and safety, health care and Gerontological nurses can leverage this growing
health challenges, mental health, and self- interest in aging by enhancing their knowledge
actualization. about age-friendly movements, influencing these
movements with their expertise in evidence-based
Evidence-based practice practices, and advancing their own competencies
 Clinical decision making is based on the best in caring for older adults in any setting.
available research.  What is the standard assessment tool for older
 The health care provider identifies each adults?
patient’s unique health status.
 The risks and benefits of any intervention is The geriatric assessment is a multidimensional,
evaluated. multidisciplinary assessment designed to evaluate
 Includes the patient’s preferences and values. an older person's functional ability, physical health,
cognition and mental health, and
ANA STANDARDS OF socioenvironmental circumstances.
GERONTOLOGICAL NURSING  What are community-based services for the
PRACTICE (NURSING CARE) elderly?

 STANDARD I: Assessment: The gerontological CBSS provide (and act as a link to) specific
nurse collects patient health data. resources for older adults and their caregivers that
include wellness programs, nutritional support,
 STANDARD II. Diagnosis: The gerontological educational programs about health and aging, and
nurse analyzes tha assessment data in counseling services for caregivers, as well as
determining diagnosis. general assistance with housing, finances, and
home safety.
 STANDARD III. Outcome identification: The
gerontological nurse identifies expected  What are chemical restraints for the elderly?
outcomes individualize to the older adult.
The primary types of chemical restraint used are
 STANDARD IV. Collegiality: contributes to psychopharmacological drugs, which impact an
professional development of peers, colleagues individual's behavior, mood, thinking, and
and others. sensation. These drugs are known to rapidly
sedate or relax a patient who behaves violently or
 STANDARD V: Ethics: decisions and actions
unmanageably.
on behalf of older adults are determined in an
ethical manner.
Ethico -Legal Considerations in
 STANDARD VI: Collaboration: collaborates the care of Older Adult
with older adult, the older adults caregiver, and
all member of interdisciplinary team to provide A. Laws affecting Senior Citizens/Older Persons
comprehensive care. (RA 7432, RA 9257, RA 9994)

 STANDARD VII: Research: interprets applies B. Medication of Older Adults (Polypharmacy)

and evaluates research findings to improved C. Ethical Principles
gerontological nursing practice.
D. Long Term Care
 STANDARD VIII. Resource Utilization:
considers the factors related to safety, E. Palliative Care
effectiveness and cost in planning and
delivering patient care. F. Advance Directives / DNR

G. End – of Life Care

H. Care of the Dying and the Dead

I. Spiritually among Older Persons

 J. Ethical Dilemmas AMENDED BY REPUBLIC ACT NO. 9257 OF
2003 RULE I TITLE, PURPOSE AND
 Palliative care is specialized medical care that CONSTRUCTION.
focuses on providing relief from pain and other
symptoms of a serious illness. It also can help Article 1. Title. - These Rules shall be known and cited
you cope with side effects from medical as the Implementing Rules and Regulations of
treatments. Republic Act No. 9994, otherwise known as the
"Expanded Senior Citizens Act of 2010."
A. Laws affecting Senior Citizens / Older
Persons (RA 7432; RA 9257, RA 9994) Article 2. Purpose. - Pursuant to Section 9 of RA No.
RA 7432 - AN ACT TO MAXIMIZE THE 9994 (hereinafter referred to as the Act), these Rules
CONTRIBUTON OF SENIOR CITIZENS TO NATION and Regulations are promulgated to prescribe the
BUILDING, GRANTS BENEFITS AND SPECIAL procedures and guidelines for its implementation, in
PRIVILAGES. order to facilitate compliance with the Act and to
achieve its objectives.
 Section 1. Declaration of Policies and
Objectives. — Pursuant to Article XV, Section Article 3. Construction. - These Rules shall be
4 of the Constitution, it is the duty of the family construed and applied in accordance with and in
to take care of its elderly members while the furtherance of the policies and objectives of the law. In
State may design programs of social security case of conflict or ambiguity, the same shall be
for them. construed liberally and in favor of the senior citizens.
 In addition to this, Section 10 in the RA 9994 -AN ACT GRANTING ADDITIONAL
Declaration of Principles and State Policies BENEFITS AND PRIVILEGES TO SENIOR CITIZENS,
provides: “The State shall provide social FURTHER AMENDING REPUBLIC ACT NO. 7432, AS
justice in all phases of national development.” AMENDED, OTHERWISE KNOWN AS “AN ACT TO
Further, Article XIII, Section 11 provides: “The MAXIMIZE THE CONTRIBUTION OF SENIOR
State shall adopt an integrated and CITIZENS TO NATION BUILDING, GRANT
comprehensive approach to health BENEFITS AND SPECIAL PRIVILEGES AND FOR
development which shall endeavor to make OTHER PURPOSES”
essential goods, health and other social
services available to all the people at Be it enacted by the Senate and House of
affordable cost. There shall be priority for the Representatives of the Philippines in Congress
needs of the underprivileged, sick, elderly, assembled:
disabled, women and children.”
Section 1. Title. – This Act Shall be known as the
Consonant with these constitutional principles the “Expanded Senior Citizens Act of 2010.”
following are the declared policies of this Act:
Sec. 2. Section 1 of Republic Act No. 7432, as
(a) to motivate and encourage the senior citizens amended by Republic Act No. 9257, otherwise known
to contribute to nation building; as the “Expanded Senior Citizens Act of 2003”, is
hereby further amended to read as follows:
(b) to encourage their families and the
communities they live with to reaffirm the valued “SECTION 1. Declaration of Policies and Objectives. –
Filipino tradition of caring for the senior citizens. As provided in the Constitution of the Republic of the
Philippines, it is the declared policy of the State to
In accordance with those policies, this Act aims to: promote a just and dynamic social order that will
(1) establish mechanisms whereby the contribution ensure the prosperity and independence of the nation
of the senior citizens are maximized; and free the people from poverty through policies that
provide adequate social services, promote full
(2) adopt measures whereby our senior citizens employment, a rising standard of living and an
are assisted and appreciated by the community as improved quality of life. In the Declaration of Principles
a whole; and State Policies in Article II, Sections 10 and 11, it is
further declared that the State shall provide social
(3) establish a program beneficial to the senior justice in all phases of national development and that
citizens, their families and the rest of the the State values the dignity of every human person
community that they serve. and guarantees full respect for human rights.
RA 9257 - IMPLEMENTING RULES AND “Article XIII, Section 11 of the Constitution provides
REGULATIONS OF REPUBLIC ACT NO. 9994, that the State shall adopt an integrated and
ALSO KNOWN AS THE "EXPANDED SENIOR comprehensive approach to health development which
CITIZENS ACT OF 2010," AN ACT GRANTING shall endeavor to make essential goods, health and
ADDITIONAL BENEFITS AND PRIVILEGES TO other social services available to all the people at
SENIOR CITIZENS, FURTHER AMENDING affordable cost. There shall be priority for the needs of
REPUBLIC ACT NO. 7432 OF 1992 AS the underprivileged, sick, elderly, disabled, women and
children. Article XV, Section 4 of the Constitution illness, or injury. These centers focus on
Further declares that it is the duty of the family to take restoring the physical, mental, and emotional
care of its elderly members while the State may design well-being of the elderly through various
programs of social security for them. therapies and services.

“Consistent with these constitutional principles, this Act B. Medications of Older Adults
shall serve the following objectives: (Polypharmacy)
“(a) To recognize the rights of senior citizens to take
their proper place in society and make it a concern of Polypharmacy is the concurrent use of several
the family, community, and government; different medications consumed by a person. Often
these multiple medications are in the same class and
“(b) To give full support to the improvement of the total are used to treat more than one chronic condition.
well-being of the elderly and their full participation in
society, considering that senior citizens are integral Polypharmacy is an area of concern for elderly
part of Philippine society; because of several reasons. Elderly people are at a
greater risk for adverse drug reactions (ADRs)
“(c) To motivate and encourage the senior citizens to because of the metabolic changes and reduced drug
contribute to nation building; clearance associated with ageing; this risk is
furthermore exacerbated by increasing the number of
“(d) To encourage their families and the communities
drugs used. Potential of drug-drug interactions is
they live with to reaffirm the valued Filipino tradition of
further increased by use of multiple drugs.
caring for the senior citizens;
Polypharmacy may sometimes lead to “prescribing
 How does good citizenship contribute to
cascades.” Prescribing cascade is said when signs
nation-building?
and symptoms (multiple and nonspecific) of an ADR is
Good Citizenship: Bring Out the Best in Filipinos misinterpreted as a disease and a new treatment/drug
therapy is further added to the earlier prescribed
Good citizenship will help the Philippines progress. treatment to treat the condition. This inherits the
Good citizens contribute to economic wealth, potential to develop further more side-effects and thus
peace and order, culture shaping, and political making a prescribing cascade.
maturity. Good citizens don't sell their votes; they
choose excellent servant leaders. They The symptoms caused by polypharmacy is
understand and protect their rights, and they unfortunately usually demented with the normal aging
realize their responsibilities signs and symptoms, which can be: Tiredness,
sleepiness, or decreased alertness, constipation,
“(e) To provide a comprehensive health care and diarrhea, or incontinence, loss of appetite, confusion,
rehabilitation system for disabled senior citizens to falls, depression or lack of interest in your usual
foster their capacity to attain a more meaningful and activities, weakness, tremors, visual or auditory
productive ageing; and hallucinations, anxiety or excitability, and/or dizziness.
“(f) To recognize the important role of the private sector Polypharmacy can lead to ADRs, mostly due to over-
in the improvement of the welfare of senior citizens the-counter medications. The most consistent risk
and to actively seek their partnership. factor for ADRs is the number of drugs being taken, i.e.
“In accordance with these objectives, this Act shall: as the number of drugs taken increases, the risk of
ADR increases exponentially. Polypharmacy may also
“(1) establish mechanisms whereby the contributions lead to decreased medication compliance, poor quality
of the senior citizens are maximized; of life, and unnecessary drug expenses.

“(2) adopt measures whereby our senior citizens are To reduce the incidence and adverse effects of
assisted and appreciated by the community as a polypharmacy medication regimes of elderly patients
whole; should be evaluated monthly.

“(3) establish a program beneficial to the senior A single agent/drug should be prescribed instead of
citizens, their families and the rest of the community multiple drugs for the treatment of a single condition, if
they serve: and possible.

“(4) establish community-based health and Medications should be started with the lower drug
rehabilitation programs for senior citizens in every dosage where clinically indicated and if required
political unit of society.” incremental increase can be done.

 Rehabilitation centers for the elderly are Drugs that can be given once or twice a day should be
specialized facilities that provide preferred over the drugs given three times a day.
comprehensive care and support to older
adults who are recovering from surgery,
Drugs that are suspected to cause a problem should DILEMMA
be discontinued. If the drug taken has no therapeutic A true dilemma occurs when it appears there are no
beneficial effect or clinical indication it should be acceptable choices. To qualify as a dilemma, there
eliminated. must be active engagement in the situation that forces
Unessential drugs should be identified and eliminated an evaluation of and need for choices. Actions are
prescribed by different health care providers for the uncertain because alternatives are equally
same condition/disease. Safer drugs should be unattractive.
substituted with the higher risk medications. Dilemmas are inherent in the health care of the
Identifying and avoiding the polypharmacy can lead to geriatric population, creating ethical problems for those
better outcomes in the elderly patients and also helps providing care.
in improving the quality of life. Difference in values and opinions can lead to conflicts
Medication review is an essential part in the elderly between caregivers and health care providers and are
patient to avoid adverse effects that can be caused more common in diverse communities where cultural
due to polypharmacy. values may be quite different.

C. Ethical/Legal Principles and Issues MORAL PRINCIPLES

The ethics of care include compassion, equity, Moral principles – incorporated into professional code
fairness, dignity, confidentiality, and mindfulness of a of ethics, organizational value statements, and position
person’s autonomy within the realm of the person’s statements published by professional groups such as
abilities and mental capacity. the American Nurses Association (ANA).

Ethical concepts are principles that facilitate decision This code forms the cornerstone of nursing practice.
making and guide our professional behavior. They The purpose of this code is to provide nurses with
evolve from our beliefs and values, and therefore have tools for identifying ethical responsibilities and to guide
their foundations in religion, culture and family decision making within the primary goals, values and
expectations. obligations of the profession. (Hook & White, 2003)
Ethical decision making is driven by moral reasoning – ETHICAL / MORAL PRINCIPLES
our determination of what is right and wrong. Ethical
 ADVOCACY
concepts and personal values define our character and
 AUTONOMY
are expressed in our conduct and actions.
 BENEFICENCE / NONMALEFICENCE
Changes in our social networks, including global  CONFIDENTIALITY
awareness, cultural diversity, and advances in science,  FIDELITY
medicine and technology have created increasingly  FIDUCIARY RESPONSIBILITY
complex conflicts and dilemmas. Therefore, nurses  JUSTICE
must have a clear understanding of their own values  QUALITY OF LIFE
and strategy for decision making because a nurse’s  RECIPROCITY
personal beliefs may be quite different from the  SANCTITY OF LIFE
patient’s from the organization’s values and  VERACITY
expectations, or from the community’s public rules.
Non maleficence – always having the best interest for
CONFLICT AND DILEMMA the patient
Conflict – occurs when a choice must be made A fiduciary is a person or organization that acts on
between two equal possibilities. behalf of others and is required to put the clients’
Dilemma occurs when it appears there are no interests ahead of their own, with a duty to preserve
acceptable choices. good faith and trust12345. Fiduciaries are legally and
ethically bound to act in the other’s best interests1235.
Three (3) Types of Moral Conflict by Fiduciary relationships are often of the financial variety,
Redman and Fry (1998): but the word fiduciary does not, in and of itself,
1. Moral distress – occurs when someone wants to do suggest pecuniary ("money-related") matters4.
the right thing but is limited by the constraints of the ADVOCACY
organization or society.
Advocacy – refers to loyalty and championing of the
2. Moral uncertainty – confusion surrounding situations needs and interests of others, requiring the nurse to
in which a person is uncertain what the moral problem educate patients and their families so that they know
is or which moral principles or values apply to it. their rights, are fully informed, and are able to access
all the benefits they are entitled to. (Hoeman &
3. Moral dilemma – arises when two or more moral Duchene, 2002)
principles apply that support mutually inconsistent
actions.
Advocacy is implicit in the social contract between the FIDELITY
profession of nursing and society and is based on Fidelity – keeping promises or being true to another;
other ethical concepts such as justice and autonomy being faithful to commitments and responsibilities.(Ellis
(Falk Rafael, 1995). & Hartley, 2004.)
Our increasingly complex health care system often Fidelity is particularly important in the care of geriatric
calls for advocacy efforts to help patients and families patients because of the amount of trust they put into
negotiate it and receive appropriate services. the heath care system.
Nurses also advocate for patients by supporting them Fidelity is also important in relationship with team
in their efforts to retain as much autonomy as their members and the organization at which the nurse
abilities allow. works.
Advocacy also refers to maintaining the status of safe FIDUCIARY RESPONSIBITY
care. The nurse is committed to the well – being of the
Fiduciary responsibility – using both fiscal reserves
patient and thus must take appropriate action in the
and caregiving resources wisely, potentially requiring a
event that incompetent, illegal, unethical or impaired
cost-benefit analysis to facilitate decision making.
practice puts a patient at risk.
Fiduciary responsibility and fidelity are some of the
AUTONOMY
moral principles that help to determine what is just.
Autonomy – the concept that each person has a right
to make independent choices and decisions. Inherent JUSTICE
to it is respect for another and their decisions and that Justice – refers to the fairness of an act or situation.
each person should be treated with dignity as a unique Health care is replete with issues of justice.
individual with inherent worth.
QUALITY OF LIFE & SANCTITY OF LIFE
Informed consent – making sure that consent has
Quality of life – one’s personal perception of the
been granted, not assumed. It is not compliance, but
conditions of life.
ensuring that voluntariness is honored.
Quality of life is a perception based on personal values
Paternalism – distribution of power in relationships with
and beliefs. Views on quality are widely variable and
patients and families.
likely to change when circumstances differ. They are
BENEFICENCE / NONMALEFICENCE influenced by emotional, physical, economic and social
needs.
The concepts of do good (beneficence) and do no
harm (nonmaleficence) are integral to health care. Quality of life is enhanced by prevention and
Nurses intend to do good for their patients. Nurses are management of chronic disease through preventive
also concerned about situations that can result in harm care, support for healthy lifestyle choices, education
to patients, such as understaffing. and home evaluations to reduce risk of injury.
Failure to Rescue Sanctity of life – value of life and the right to live.
Failure to rescue – it is the effectiveness in rescuing a
Sanctity of life supports the belief that all life is value
patient from a complication versus preventing a
and that this value is not based on how functional or
complication. It has many causes, from situations as
effective a person’s life is, simply that we all have a
simple as educational background, inexperience, and
right to life.
lack of knowledge to more complex issues such as
attitude toward work, staffing patterns, and resource RECIPROCITY
allocation. It can be an issue of omission as much as
Reciprocity – a feature of integrity concerned with the
an issue of commission. It behooves all nurses to think
ability to be true to one’s self while respecting and
carefully about the issue of failure to rescue and to
supporting the values and views of another.
investigate practice situations so that such
circumstances are not issues of maleficence. Living according to this principle is particularly
important when values and views are different.
CONFIDENTIALITY
The ANA Code of Ethics (2001) emphasizes respect VERACITY
for human dignity that is demonstrated in daily work. Veracity – means truthfulness and refers to telling the
This includes respect for privacy and maintaining truth, or, at the very least, not misleading or deceiving
confidentiality. So much value is placed on the concept patients or their families. It forms the basis of informed
of confidentiality that it is considered a right—right to consent – without truthfulness and an explanation of
privacy. options, the patient cannot possibly make the best
choice. Failure to be truthful impairs trust and reliability
(Ellis & Hartley, 2004).

Patient Rights
Patient rights – direct actions on ethical issues in the  Taking proper steps to correct the situation.
care of geriatric populations. Rights are considered  Apologizing for the mistake
basic to human life, and each person is entitled to  Making amends as possible.
them on a legal, moral, or ethical basis.  Evaluating how to prevent such mistakes in
the future.
The most fundamental patient right is the right to
decide. Disclosure of mistakes in an honest and willing manner
reduces the threat of the situation and also reduces
Decisions regarding life-saving or life-sustaining care the threat of liability.
are recorded in legal documents known as advanced
directives. They describe actions to be taken in a Conflict of Interest
situation where the patient is no longer able to provide Conflict of interest situations arise from competing
informed consent. loyalties and opportunities.
Living Wills and Durable Power of Attorney These may include conflicts of values between the
Living wills are alternative documents that direct nurse’s value system and choices made by the
preferences for end-of-life issues, providing an “if… patients, their families, other health care team embers,
then…” plan. The “if” condition must be confirmed by a the organization, or the insurance company.
physician.
Other conflicts occur when incentive systems or other
A living will may include a durable power of attorney, a financial gains create conflict between professional
legal document designating an alternative decision integrity and self- interest. Nurses should facilitate
maker in the event the person is incapacitated. This resolution of conflicts by disclosing potential or actual
document supersedes all other general legal conflicts of interest or withdraw from participation in
designations for decision makers. care or processes that are causing the conflict (ANA,
2005a)
Competence
Competence – refers to one’s clarity and SUMMARY:
appropriateness in decision making. Nurses must respect the worth, dignity and rights of
Competence must be present for persons to exercise the elderly and must provide care that meets their
autonomy and their right to decide. comprehensive needs across the continuum. Their
fundamental commitment to the uniqueness of the
Inherent in autonomy is the right to choose, the right to patient creates opportunities for participation in
be informed and the right to refuse treatment, including planning and directing care. Their vigilance in
whether to participate in research. advocating for dignified, just and humane care
establishes a standard that can be appreciated, and
Loss of competence due to impaired memory or
potentially needed, by all of us. It is not the rules and
sensory function significantly impacts one’s ability to
regulations that create ethical care delivery; it is the
make such informed decisions.
little actions done by each and every nurse in every
day of practice.
Ethics in Practice
Ethics in Practice – ethical dilemmas and conflicts As nurses, each of us is held to the ethical standards
surround us in real life, and ethical principles alone are of practice of our profession. (Esturhuizen 1996).
not likely to address many of the quandaries and Providing respectful care that puts patient’s safety and
dilemmas occurring in the care of geriatric patients. welfare first helps us to avoid situations that can result
in failure to rescue, abuse of power, exploitation, and
Living by these principles requires reflection and over- involvement (Ellis and Hartley, 2004). Developing
consideration of one’s own beliefs and how they a framework for ethical decision making provides a
interface with the professional code of ethics, foundation for discussion when dilemmas present
organizational statements, beliefs of patients in the themselves, smoothing the way for integrity – saving
community in which the nurse practices. compromise. The nurse’s conscientious effort to follow
ethical standards in daily practices supports the quality
Mistakes of care we all want to experience.
Mistakes – mistakes happen, and happened more
often than the public was aware of prior to the 2000
report by the Institute of Medicine that stated such
errors are common and often life threatening. Since
that time, considerable effort has been put into
reducing mistakes and improving patient’s safety.

Ethical responses to mistakes include:

 Honestly admitting the error occurred in a

neutral and objective manner.