Table of contents • Aim and Introduction • Barriers, Consent and Confidentiality Aim and Introduction Lesson aim Determine when and how to intervene in the life of an elderly person Introduction As a counsellor it is important to keep abreast of ethical issues in order to help your clients in the best possible way. In order to achieve this it is necessary to remain up to date with any changes in law which might affect counselling techniques or ethical practice, to continuously update specialist knowledge, to consult with fellow professionals, and to periodically examine one’s own values and beliefs. Indeed, it may be a requirement of your local counselling body to maintain current ethical guidelines through attendance of annual seminars. Codes of ethics are available from the counselling body to which you belong or to which you intend to belong. These codes act as a guideline to assist the counsellor in making appropriate decisions in specific situations but are not intended to be completely directive. Counselling professionals are therefore expected to use them as an aid to prudent decision making, with an element of adaptability. Ethical codes are not only provided to educate practitioners, but also the general public about their rights and the responsibilities of counsellors. They therefore serve as a code of accountability, and enforcement protects clients from unethical practice. As with all areas of counselling, the aged care counsellor can opt to merely follow mandatory ethical guidelines, that is, the basic ethical code, or they can strive towards aspiratory ethics whereby they do what is best for their clients. The fear of lawsuits has meant that some counsellors adhere to legal minimum requirements at the expense of their clients. Whilst legal obligations are part of the ethical code of practice they should not be confused with acting ethically which means so much more. In spite of the fact that ethical codes for numerous professions have become lengthy documents they still require interpretation on behalf of the practitioner. Barriers, Consent and Confidentiality Barriers to aged care counselling There are some barriers which can impede effective communication that are more specific to the aged population. Such barriers include cognitive decline, psychiatric illnesses, the effect of medication, and sensory impairment. The counsellor needs to assess the motivational level of the elderly client and proceed according to their needs. As such, it is necessary to work with the client in setting priorities, time parameters, joint goals of counselling, suitable termination of counselling, and to determine when or if it is necessary to refer the patient on to another health care professional. Other issues to be considered include the budgetary constraints of the client. Furthermore, whilst a client may be elderly, a competent counsellor ought not to make assumptions based solely on age. One should take into consideration all available information from other health care professionals in conjunction with working with the client, so as to determine an appropriate counselling strategy. Addressing the client’s needs Whether counselling elderly or younger clients, it is imperative that the counsellor continuously strive to satisfy the client’s needs, rather than their own. Whilst there is nothing ethically wrong with the counsellor gaining work satisfaction, it should never be to the detriment of the client. Part of the solution to putting the clients’ needs first is to work through one’s own issues and belief systems so as to improve self-awareness and recognise areas of weakness and prejudice that one might have. In doing so, it is possible to limit interference to the therapeutic process through projection. It may also be necessary to undergo therapy oneself to work through existing conflicts which resurface during the counselling process. As a counsellor one also needs to keep in check other less disturbing needs, such as: the need for power, the need to help others, the need to feel respected and appreciated, or the need to convert others into sharing our own values. It is acceptable to have some needs met through the counselling process in order to attain a degree of job satisfaction. The problem arises when the counsellor becomes so focussed on their own need for satisfaction that the needs of their clients are not met. It is therefore an ethical obligation for the counsellor to periodically evaluate whether their own personality is negatively impacting upon the therapeutic process. Common legal and ethical issues in aged care The most common legal and ethical issues in aged care counselling involve the client’s decision making capacity and competence. In cases where the client is deemed to be unable to make competent decisions then those who are able to make decisions on the client’s behalf must be identified. It may also be necessary to resolve the client’s conflicts about receiving care through counselling before proceeding. Issues relating to disclosure of information to others, termination of treatment at the end of life, and decisions about long-term care, are also pertinent. There are similarities in the resolution of these issues across all age groups. Nevertheless, the physiological, psychological, and social reserves of the elderly place them at higher risk of unfavourable outcomes. In addition, the elderly often lack the support of family and friends which can make them particularly vulnerable to the whims of counsellors and other health care professionals. It is incumbent upon the counsellor to ensure that their clients are fully informed throughout the counselling process, and never intentionally misled. The aged care counsellor also has a duty of care to his or her client to offer assistance or referral for legal help if they suspect, as sometimes happens with the elderly, that their clients have been the victim of a scheme intended to extort money or defraud them of property or personal wealth. Decision making capacity This refers to the elderly client’s ability to make decisions about treatment interventions or other health related issues and is normally clinically determined by the individual’s GP or by a combination of health care practitioners. Typically, a measure of decision making capacity will be derived through cognitive testing, discussions over a period of time, and observations of the client. Whilst capacity is linked to memory, it is not precluded by loss of memory. An individual is considered to be capable of decision making if they are able to comprehend their health condition and in doing so can consider the benefits, risks, and potential burdens of health care options. They are able to contrast potential treatment outcomes with their own preferences and values and make a decision which remains consistent over time, and they are able to communicate that decision to others. It should be noted that an elderly client with decisional capacity has the same rights as younger adults to determine their care choices. A counsellor is unlikely to deal with clients who have only partial capacity or who are incapacitated. Those with partial capacity may have reduced or fluctuating capacity, for example, they may become confused at the end of the day: known as sundowning, but they may be able to make health care decisions at other times when they are more lucid. Another example is clients with short term memory loss, such as, with Alzheimer’s Disease. These clients would need to retain current information in order for counselling to be effective. Where the disease has progressed significantly, counselling will be ineffective other than to provide a temporary sense of well being. When an elderly client becomes incapacitated then decision making becomes the responsibility of both the family and care providers. If possible, it is therefore important for the counsellor and other health care professionals to discuss treatment options and ongoing care plans before the client loses the ability to make informed decisions and communicate those choices. Competence Competence is a legal assertion which acknowledges that people over the age of 18, in most countries, have the cognitive ability to undertake various legal tasks, such as, making a will, signing a contract and so on. Conversely, incompetence, which can only be decided by a court of law, is an assertion that an individual lacks certain cognitive abilities and therefore has limited legal rights. It is derived from a thorough assessment of the person’s abilities and disabilities. Such individuals are declared a ward of the state, or court, and are appointed a guardian. The counsellor needs to be aware of elderly clients’ competency status. All adult clients who are not intellectually disabled or who have not been declared incompetent by a court share the same legal rights. Unfortunately, elderly clients are often at higher risk of having their legal rights revoked because they are more likely to be alone, impoverished, confused, demented, or institutionalised. They may find it more difficult to articulate their beliefs and wishes, and often have a limited social support network. The ethical onus is therefore on counsellors and other health care workers to identify and support the rights and interests of elderly patients, to ensure that they are not deliberately or accidentally stripped of their authority. Informed consent This refers to a client’s decision on how to proceed with therapy. The decision must be reached voluntarily by the client based upon information provided by the counsellor in relation to risks, rewards, possible outcomes, and alternative treatment strategies. In doing so, the client becomes an active participant in the therapeutic process. This is also the time for the counsellor to discuss any fees, the estimated length of the therapeutic process, confidentiality, legal and ethical issues, and the client’s and counsellor’s responsibilities. The counsellor needs to be wary of bombarding the client with too much information, or not providing enough information, and so needs to assess each client’s needs accordingly. Several legal principles form the basis for informed consent. The right of knowledgeable self determination and choice obligates the counsellor to inform clients of the possible risks and benefits of alternative approaches. The right to privacy, as well as the concept of personal freedom enables the client to choose an individually appropriate course of treatment. Self determination, or autonomy, is the notion that every adult of sound mind has the right to decide what is to be done in relation to them. It is the cornerstone of the legal and ethical doctrine of informed consent. Only when decision making is preceded by discussion with a counsellor who provides the client with the necessary information for choosing among options, can the client’s consent, or refusal to consent, be said to be informed and therefore ethically valid and legally binding. The process of informed consent may be more difficult with elderly clients because of age-related problems, such as impaired sensory functions or cognitive deficits. It is, therefore, very important to ensure that the client understands the options being discussed through feedback and clarification. It may be that more time is required to allow the client to discuss the way forward. The counsellor should also be wary of family influence through the process of ‘learned helplessness’ which may occur where elderly clients are institutionalised. This is particularly a problem in long term care facilities, or with the individual’s GP. In cases where elderly clients request that a family member is present, due to suspicion or dependence, then that decision should be respected. If the client concedes their autonomy to a sibling or other person, then again the counsellor should include that person in the counselling process. In such cases the counsellor should still try to include the client in discussions at regular intervals and keep them informed. If an elderly client decides to refuse further counselling or wishes to end the therapeutic process then once again this decision must be respected, even if it makes little sense. The counsellor may attempt to encourage the client to engage in counselling if they believe it to be in the client’s best interest, but they should never attempt to coerce the client into participation. As with other clients, if conflicts arise between the counsellor and client, whether personal, or in relation to the therapeutic goals, and these conflicts cannot be resolved through mediation or negotiation, then the counsellor must refer the client to another health care professional. Confidentiality Confidentiality comprises both ethical oaths and legal statutes. It is the key to developing a trusting working relationship between the counsellor and client. Confidentiality may be breached simply by involving well meaning family members without first acquiring the client’s consent. The protection of private client information is paramount to encouraging the client to engage openly in therapy. Protection of a client’s secrets, private thoughts, and feelings are also required by decency. Counsellors are obliged to discuss the nature and scope of confidentiality with their clients, and also reveal any limitations to confidentiality. For example the counsellor should reveal the fact that they may discuss certain aspects of the client’s case in a professional manner with supervisors, colleagues, or other professionals related to the case. Many professional licensing bodies incorporate the legal and ethical confidentiality mandates and highlight them as an important part of professional practice. All clients are entitled to confidentiality unless they have given permission for disclosure, or they can obviously no longer express a preference, for example, they are confused, delusional, demented, incapacitated, and so on. Even in these cases, secrets and private thoughts should not be disclosed, although decisions about future therapy may require discussion with appropriate guardians, family members and so on. If an elderly client becomes incapable of making health care decisions, then any preferences which may have been indicated prior to the commencement of counselling should be undertaken if possible. There are times when confidential information must be divulged, and at such times the stipulations of the institution and clientele must be considered. Prudent judgement may be drawn upon where circumstances are not clearly defined. However, confidentiality has to be broken if the counsellor suspects that the client is at risk of harming themselves or others. Also, as with child abuse, confidentiality has to be breached and cases reported where abuse of the elderly is discovered or strongly suspected. In addition, client information must be legally reported if the elderly client is in need of hospitalisation, a court has requested the information as part of court proceedings, or if the client requests that their personal file is released to themselves or a third party. In instances where students are discussing particular cases, particularly in group discussions, it is important to maintain client confidentiality through protecting the individual’s identity. Not using names or using initials only, are ways that this can be achieved and in doing so retain a code of professionalism. Euthanasia Euthanasia is described as an action undertaken by a health care worker intended to result in a client’s or patient’s death. It is illegal in most countries. If a counsellor engages with a client whose life expectancy is reduced and who is suffering severely, they may wish to discuss euthanasia. However, euthanasia is forbidden in any area of medical practice and the notion of deliberately ending life is upsetting for most counsellors and clients. However, in certain specific clinical situations where the client has become hopeless in their intense suffering, then death might be regarded as bringing an end to incessant pain, rather than termination of meaningful life. Nevertheless, the counsellor’s role is to engage in a therapeutic process with the client in order to reduce psychological, emotional, and physical suffering, and not to play a role in hastening the client’s death. If the counsellor becomes aware that the client is not taking their medication and are at risk as a consequence, then once again they would need to breach client confidentiality. Assisted suicide, whereby a patient or client acts with the intention to cause his or her own death with medication provided by a GP is also illegal in most countries. Palliation, or pain relief, is inextricably linked to assisted suicide because: a number of dying patients experience constant pain or other unbearable symptoms, and the majority of patients seeking assisted suicide just want an end to the suffering, rather than truly wanting to die. Multicultural differences As with counselling younger adults, it is important for the counsellor to consider multicultural differences when counselling the elderly client. Many counselling perspectives have evolved from consideration of white, middle class, middle aged people living in Western societies and so members of minority groups such as the elderly are not well catered for. To treat all clients in the same way would be unethical. Also, whilst the goal of counselling is typically to encourage individualism this may not be helpful for Asian clients, for example, where inter dependence on group members is more important. It is necessary, therefore, for the counsellor to examine cultural and environmental factors in order to understand the client. Values which may be pertinent in a Western society are not suitable for all clients. Hence, the counsellor who is treating an elderly black man needs to adapt their approach so as to determine what is best for the client. A multicultural perspective will seek to facilitate change through social action rather than through change by enhancing the individual’s insight into their problems. However, given that it may be difficult or impossible to bring about change through social action, it may be possible for the counsellor to encourage change by helping the client identify how they are affected by external factors and challenging them to make decisions to change themselves. Therefore, the individual and the environment both play an important part in therapy. In addition, the counsellor should be wary of cultural differences if making diagnoses since errors can be made. Behaviours may be incorrectly labelled because they do not sit comfortably within the prevailing culture.