Should Older People Be Protected From Bad Choices? 

I. What makes your life worth living? What makes it satisfying?

1.Can you list the things that define a "good quality" of life for you? Stop and make a list.

              Now, rank your list placing the most important items first.

Mine included:

• vibrant health for my family and me
• meaningful friendships, relationships, and activity
• satisfying communication with family and friends
• enough money to be comfortable and have some extras
• a place to garden and to be in nature
• a comfortable home
• leisure time

2. Now try to imagine yourself as Uncle Bert, the 79 year old man whose case is used as an example throughout this chapter.

List the things that would constitute a good quality of life for you at his age (age79).

• Are their similarities? Is your list much different?
• What conclusions do you draw from this exercise?

I did not  find significant differences between what I anticipate I will want at age 79 to feel satisfaction in my life, and what I want today. Did you?

We all have a need to feel safe, to feel like we belong, to have self esteem and to feel like we have meaningful activity. 

II. Maslow's Hierarchy of Needs

1. As we learned in the chapter on Meaning in Old Age, Abraham Maslow was a Humanistic Psychologist who viewed human needs as arranging themselves according to a  hierarchy of needs.  I would like to first review that information and then go into a bit more detail here regarding Maslow.
   
2. The hierarchy consists of five levels and is shaped like a large triangle with our basic food, clothing, and shelter needs forming the base of the triangle (see diagram below) . 

 

There are lots of visual graphs on the web of Maslow's theory. Just put Maslow in any search engine and you'll see. The follow two  graphically display Maslow's theory. The first shows the hierarchy concept, and the fact that people who self-actualize (the highest level obtainable by humans according to Maslow), are smaller in number than people who fulfill their basic needs. The second graph lists the needs as associated with each tier.

Physical Needs	Safety Needs	Love Needs	Self-Esteem Needs	Self-Actualization Needs
Food/thirst Sleep Health Shelter clothing	Security Protection Comfort Peace Order	Acceptance Belonging Love/affection Participation	Recognition/prestige Leadership Achievement Competence Strength/intelligence	Fulfillment of potential Challenge Curiosity Creativity Aesthetic appreciation

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1. Needs grouped on this first level have the greatest intensity and must be met before one can move up or even desire to move up,  to a higher level of human needs. These lower needs are necessary for the survival of an individual.  If lower needs are unsatisfied, these needs can dominate a person's thoughts and actions. For example, a starving person may have no interest in the human need for belongingness. 
2. The second level in the hierarchy consists of our safety and security needs. After one is fed and clothed, the need for protection from danger, and freedom from fear become important. But until hunger is satisfied, safety and fear do not dominate a person's thoughts.
   
3. When we are reasonably safe, we may begin to express the need for love and belongingness.

• We desire friends, lovers, children. If we do not get them, we become lonely, just as we become hungry without food or frightened if safety needs go unsatisfied.

4. If love and belongingness needs are satisfied, needs for esteem emerge. According to Maslow,  humans need to respect themselves and each of us needs the respect of others.
   
5. At the top of Maslow's hierarchy is the need for self-actualization.

• Self actualization is defined as the desire to become everything one is capable of becoming. According to Maslow, humans strive for self actualization. We need truth, honesty, beauty, justice, order and playfulness. We also strive for joy and satisfaction .

III. The Concepts of Life Satisfaction 

1. We run into serious difficulties when trying to measure and interpret life satisfaction for another person, because each of us are satisfied by our own  subjective criteria.  That is, satisfaction is determined by what is reported by the subject (person) themselves.  Each person decides what constitutes life satisfaction.
   
2. For example, your list was probably somewhat different from mine.
   
3. So when caring for a vulnerable population such as Uncle Bert, how do we determine what satisfaction is for them? And how and when do we decide that someone's self measurements of satisfaction are maladaptive?
   
4. In other words, what determines a person's competency to decide their subjective measures of a satisfying life???? Deep question -- and not easy to answer.

IV. Measuring Competency 

Rarely is competency based on a standard assessment tools. Instead a variety of areas in ones life are assessed. The most common areas are:  

1.  social resource assessment
2.  economic resources assessment
3.  mental health assessment
4.  physical health assessment
5. ADL's (activities of daily living, like bathing, dressing ,etc.) assessment.

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However, more often competency is based on:

• an elder's ability to assimilate relevant facts ( person, place and time).
   Do they know their name, where they are, and today's date.
• the ability to understand one's situation.
• understand the facts about one's situation.
• ability to engage in rational decision making.

This can be a very subjective assessment on the part of the person doing the assessing.

For example, when my father-in-law (Maury) was 89 years old he was the  caretaker for his wife. He has been color blind since birth. After a  hospitalization, for my mother-in-law,  home care was ordered and the social worker called to get directions to their home.

When the social worker called, Maury  was busy toileting my mother-in-law (while trying to answer the telephone with the other hand). Wanting directions to the home the social worker asked dad "what color is your house "?  In the confusion of the moment and his colorblindness, he told her, "well I'm not sure".

When the social worker finally arrived she asked to  check the medications Maury was giving to my mother in law. She asked him to produce a medication that had been prescribed by the doctor using the generic name (the prescription bottle sported the trade name). Despite a well organized system, Dad was unable to find the requested drug because the generic and trade name were different. 

The social worker called me to tell me he was incompetent and should not be mom's caretaker. Based on her initial assessment she felt that they both should be institutionalized. Even though he managed his bills, shopped for food, cooked three meals every day, and was care taking his wife.

As you see, assessments can be flawed and often reflect the social values or norms of the person doing the interviewing. Not only can their values label an elders as maladaptive, but if their questions are not seen as relevant to an elder, the elder's answers may reflect frustration of the moment and not their knowledge. 

If Maury had known he was being assessed for competency by recalling the color of his home, his answer might have been quite different.  Other times, an elder may not hear or understand the question and choose not to ask for clarification for various reasons (embarrassment usually). This too can be interpreted by the assessor as incompetence. Lastly, often the values of the person doing the assessment ( such as the social worker in this case) label behavior as maladaptive when in fact the elder is getting along just fine. 

V. Protecting The Vulnerable or "Parents Patria" 

This term refers to the legal powers of the State to protect those who cannot protect themselves.

Unlike police power, which is aimed at protecting us from others, this focuses on the incapacitated and gives the State power to protect those who cannot protect themselves.

1. Least Restrictive Alternative 

• Least restrictive alternative is a legal doctrine first adopted by the mental health profession and has gained 
  wide acceptance among courts and service professionals. It is a widely used guideline for the powers of the State. 
  
• This doctrine creates an ethical duty for practitioners to fashion individualized solutions for elders that are least intrusive upon the elder's personal freedom. For example my father-in-law might have benefited from a chore worker or housekeeper and may not have required institutionalization. 
  
• Least Restrictive Alternative applies to personal and environmental care of the elderly, and is required to address only the needs or the areas of concern.

For example, elders may have capacity in some areas (such as Maury does in shopping, cooking and care taking) and lack capacity in others. An elder may be able to take care of their ADL's (activities of daily living) but not remember to pay the light bill. In this case, a person who could serve as a payee might avoid unnecessary institutionalization. 

• The more restrictive the intervention, the greater the due process (court hearings) required and the more opportunity there is for an elder to object and state their preferences. Elderly who are being conserved (placed under the protection of the State)  are allowed to be present  at their own hearings and often testify on their own behalf.

VI. Hierarchy of Restrictive Options:

When the State gets involved, the legal options begin with the least restrictive (example: the client handling their own affairs) and then options move up (like a ladder) to more restrictive care.

1. The hierarchy might look like this

• First a forgetful or frail elder may sign their own name to personal checks, but someone else fills out the
  amounts for light bills, doctors, etc.
  
• As deterioration increases income checks may be directly deposited into the elders bank account.
  
• As need increases, a representative payee arrangement may then be assigned by the court; someone to deposit funds and write checks for bills and personal needs while the elder continues to sign their own checks. 
  

• The next level of financial care might be a joint tenancy on bank accounts. The court assigns someone who can now sign checks for the elder.
  

• Power of attorney may be assigned next. The court assigns someone who can make legal and financial  decisions for an elderly like selling a home, purchasing insurance, etc.
  

• Finally as deterioration continues the court may issue protective orders for placement or medical treatment and assign  guardianship of the estate to someone. At this point the elder can no longer dispose of their own property.
  

• The most restrictive option would be involuntary placement in a locked mental health facility.

    2. What are the Courts Looking at when they impose these limitation?

In the absence of a clear definition of competency, courts tend to define competency in terms of the working characteristics of an individual's life . What are the everyday realities of competency?

• The current trends of defining competency look at many factors and not just decision making capacity.
• What does the elder actually do to take care of their ADL's and manage their money and assets?
• The court looks at past decisions (was the elderly in the habit of giving away money to strangers?)
• What are the medical and psychiatric diagnosis and functioning level?
• They look at variables that may have affected their functioning such as malnutrition, isolation, grief states, medication, relationships, self esteem or personal and environmental support.

3. As you can see, competency is a complex issue and there is no single tool to assess competency. So, how do we help 
    elders who are in danger of being exploited?

• Usually, court decisions hinge on the quality of life or life satisfaction of the elder.
  
• But how we measure life satisfaction, as you have seen, is a big problem. In Gerontology we often use an instrument called, Life Satisfaction Index. Here is an example of one http://www.healthnewsnet.com/aging.htm  . This instrument measures, zest for life, apathy, attainment of life's goals, and mood.  
  
• But satisfaction reflects individual coping styles and capacity for adaptation also. 
  I may feel satisfied at a living situation where my emotional needs are met, but not my food, bathing or personal hygiene needs. Then the issue of quality of life must be assessed.
  
• Determining quality of life is as difficult as determining satisfaction.

4.  Is there ever justification for intervention?

Is there justification for government intervention into our lives as we get older?

Just because an elder takes risks as Bert did walking late at night in a dangerous neighborhood, or follows unorthodox medical treatment, (or can not recall the color of  his house)  does that constitute a poor quality of life or bad choices?

Consider this: often, young people act in risky ways (perhaps driving to fast, unprotected sex, rash decision making) .As a society we have come to accept this. Does age make a difference? The issues again hinge on competency, and again we look at what defines competency, and deciding when someone is legally fit or qualified to take charge of their own lives? It is not always an easy process.

Sometimes gerontologists use the term self neglect when assessing the need for intervention 

• Self neglect usually results from physical or mental impairment. A person cannot take care of their ADL's (activities of daily living).

Again, how do we determine self neglect?

Its is not easy because it hinges on the competency issue again.

• Often we look to see if the behaviors are antisocial or life-threatening. 
  But who decides? Teenagers engage in antisocial and life threatening behaviors, does that make 
  them guilty of self neglect and at risk for government intervention into their decision making process?
  
• What if the elder refuses outside help, or passively sabotages it by not showing up for doctor appointments or refusing to take medications?

When neglect occurs it is often hard to determine whether the neglect was the result of a consciously determined free choice,  some deeply rooted unconscious factor like helplessness, or the result of a mental or  physical illness. For example: while working for the County Public Health Department I visited elders in their homes. I found an 89 year old woman with stacks of pizza boxes in her back porch. When I questioned her about them (after establishing trust) I found that she can no longer shop and the pizza parlor is the only place in our small rural community that will deliver to her home. So she lived on pizza. A simple intervention, such as home delivered meals, greatly improved not only her health but the quality of her life. 

THE END

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