518 Home Healthcare Nurse vol. 21 • no. 8 • August 2003

Beatrice B. Turkoski, PhD, RN

Is it Abuse, or Just Not Coping?Home care nurses are often the first professionalsto interact with the family in the home and arethus in a unique position to identify abuse or thepotential for abuse. Even for an experiencedhome care nurse abuse is not always easy to iden-tify or address. Reporting abuse is mandatory inevery U.S. state. Blatant and deliberate physical,emotional, or psychological harm is usuallyreadily identifiable.

However, some abuse is more subtle, andthe distinction between resolvable situa-tional stress or a lack of understanding andabuse is not always clear (Shyu, 2000). Itoften falls to the professional caregiver to de-cide between working with a family to re-solve a marginal home situation or making areferral to appropriate authorities (Welfel,Danzinger, & Santora, 2000).

Working with families in marginal or po-tentially abusive situations requires alert-ness, an understanding of family dynamics,and the skills to help a family resolve theirproblems before they turn into crises. Thecase below illustrates how one nurse foundherself in an ethical dilemma about possibleelder abuse and how she worked through toa satisfactory resolution.

Elder abuse, neglect, and exploitation are major problems today (Marshall, Benton, & Brazier,

2000). Most elder abuse occurs at home and is committed by spouses, children, or other family

members. Abuse may go undetected until observant professionals intervene (AOA, 1998).

Sometimes the abuse is a continuation of existing dysfunctional family dynamics. More often,

however, the abuse is a result of changes brought about by an older person’s growing

dependency and need for increased care.

Ethical Dilemma

The Story of JersikJersik is a 76-year-old man who immigrated fromRussia at the age of 24. After his wife died he con-tinued living alone until about 1 year ago when hehad a mild stroke. At that point, Jersik moved inwith his 36-year-old grandson, Max, and his family.

Max’s job requires out-of-town travel for sev-eral concurrent weeks, but his wife, Christine,

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and their two children, John, age 17, and Maggie,age 10, made Jersik feel a part of the family. In fact,even though Jersik speaks perfect English, thegreat-grandchildren have learned to speak a bitRussian with him. Jersik has three other childrenwho all live out of state. He has had very little con-tact with them since his wife’s death.

Two months ago, Jersik had another strokethat left him with considerable residual impair-ment. He can transfer from bed to wheelchair withsome assistance and he is able to feed himself ifthe food is cut into small pieces. He is continentbut needs help with toileting and almost all as-pects of personal care.

The home care nurse is involved withthe family because Jersik developed de-cubiti on his coccyx and one heel beforehe was discharged from the hospital. Thenurse has instructed Max’s wife, Chris-tine, in the procedure for changing Jer-sik’s dressings and stressed the need forregular daily dressing changes.

Conflicts Between EthicalPrinciplesAfter a week or so the nurse becomesincreasingly concerned about the care Jersik is re-ceiving. Christine is not consistent in changing hisdressings and often leaves her 10-year-old daugh-ter in charge of Jersik when she goes out to playgolf or shop. Jersik is often left in bed for long pe-riods and when he is up he just slumps in hiswheelchair, sitting alone in his small room.

Since the second stroke, Jersik has been mildlyconfused, especially about time-related events.But he knows where he is and has no complaintswhen the nurse asks him about his care. In fact, headamantly insists he is happy and likes being withhis family. Any mention about his moving to a carecenter causes an extreme reaction; he starts toshake and yell loudly (in Russian) about this beingthe United States and not a Russian prison.

Although the nurse is concerned about Jersik’scare, she is equally concerned about contacting aprotective services agency, because doing so wouldlikely isolate Jersik from his family. She decides todiscuss this with her agency’s newly formed ethicscommittee, a multi-disciplinary resource for resolv-ing patient care dilemmas (Fry, Cunningham, Fa-jkowski, McCormick-Gendzel, & Day, 2001).

Jersik’s case illustrates an ethical dilemma be-tween the principles of beneficence and non-maleficence and between justice and autonomy.

Beneficence: What Does “Doing Good” Mean?Beneficence is an ethical concept embedded inthe very raison d’être of healthcare; the idea ofdoing good for people in our care. Doing good,however, incorporates more than just competentcare for a specific health problem. In this casedoing good for the patient means helping Jersikmaintain his dignity and emotional health in addi-tion to treating his decubiti.

As Beauchamp and Childress (1994) point out,ethical dilemmas require weighing the merit ofethical arguments by looking at the potential goodin relation to the potential harms. The difficulty

here lies in determining who can best evaluate theextent of the good or harm of leaving Jersik in aminimal care situation versus the good or harm ofmoving him out of the home.

The nurse does not think Jersik is receiving thecare he needs. His dressing is not being changedas often as it should, and she suspects that hemay not be getting appropriate nutrition. She alsoobserves that Jersik is often left alone in his room.Approaching this situation from an objective jus-tice approach, the nurse may feel that rules mustbe followed (Botes, 2000).

Jersik is not receiving the care prescribed;therefore, the case should be reported to Protec-tive Services. Conversely, Jersik insists he is get-ting what he needs, and more importantly, hissense of self and his socialization needs are beingmet by being with his family.

Nonmaleficence: Expert Care vs.Family BondsThe ethics committee is also concerned about theprinciple of nonmaleficence. Moving Jersik out ofthe family home may appear to be an act of doinggood. For example, he would receive better carefor his decubiti. However, isolating Jersik from hisfamily could also be harmful. There is no care fa-

Each case of elder abuseneeds to be reviewed on anindividual basis.

520 Home Healthcare Nurse vol. 21 • no. 8 • August 2003

cility close to his family and, with Max often gone,it would be more difficult for Christine or the chil-dren to visit Jersik. This is his only family. He haslived with them for more than 1 year, and despitecertain lapses in his care, he is always clean andhis room is clean.

AutonomyAutonomy and the respect for an individual’sright to self-determination are also a considera-tion in this case. While Jersik may have lost somemental acuity, results of a mental status assess-ment done while Jersik was in the hospital do notsupport a declaration of incompetence. Wheneverthe nurse has mentioned moving Jersik to a carefacility he has been very clear about how he feels.

The Committee’s DecisionAfter much discussion and deliberation the ethicscommittee did not think that this situation war-ranted notifying Protective Services until severalother approaches were tried. Their recommenda-tions included a conference with the nurse, the so-cial worker, Caroline, and Max to gauge their un-derstanding of Jersik’s needs.

For any family, such a meeting must be donewithout blaming or creating internal family fric-tion. During this conference the nurse can also:

• explain why the dressing changes are impor-tant and what could happen if the regulardaily schedule is not followed and the decu-biti do not heal;

• identify if Caroline feels trapped and over-whelmed by the responsibility for Jersik’s in-creased level of care;

• encourage the family to engage appropriaterespite care for Jersik that would allow Caro-line time outside of the home;

• remind the family that a 10-year-old may notbe mature enough to be responsible for Jer-sik’s care;

• arrange a consult with a dietitian if the familydoes not object. Proper nutrition and hydra-tion will benefit wound healing for Jersik.Preparing foods that Jersik can pick up withhis fingers would also relieve Caroline of al-ways having to cut up his food.

Sharing with Family—Revising the Plan of CareAt the meeting with Caroline and Max it becameapparent that both felt overwhelmed by Jersik’s

current needs. However, they were both appalledat the idea of moving him to any kind of care facil-ity and insisted they wanted to keep him in theirhome as long as possible. They also commentedthat all of Jersik’s social security and retirementincome was banked in his name. Therefore, no fi-nancial exploitation was involved.

Caroline said she felt inadequate about chang-ing the dressings and had not fully understood theseriousness of Jersik’s decubiti. She welcomedthe nurse’s offer of specific, detailed, written di-rections for the dressing changes and asked if thenurse could stand by and guide her until she feltmore competent.

Max and Caroline also agree to contact a re-tired nurse in their neighborhood who frequentlyprovided respite care, and to arrange for regular“time-off” for Caroline. Caroline felt she did notneed any dietary instruction but added that shehad not thought of serving finger food for Jersik.

Both Caroline and Max said that Jersik seemedto want to remain in his room most of the time.They agreed that perhaps Jersik was ashamed ofneeding so much more help because he had beena very proud, “manly” person before his stroke.When the social worker pointed out that this didnot provide social interaction for Jersik, Carolineand Max promised to make a greater effort to per-suade him to join the family in the living room oron the patio.

In this case the principles of beneficence, non-maleficence, justice, and autonomy were incorpo-rated into a successful resolution. The patient’sbest interests and his wishes were respected, andthe family remained close and supportive. The po-tential for physical abuse and the potential of dis-rupting Jersik’s emotional health were avoided.

ConclusionEach case of elder abuse needs to be reviewed onan individual basis. Often, even a minimal caresituation can be strengthened so that the eldercan safely remain in their home. In other in-stances, it may be in everyone’s best interest tonotify Protective Services. Each home care nurseneeds to be aware of the state and federal regu-lations that govern reporting abuse in the pa-tient’s jurisdiction.

Discussing the case with experienced peersand seeking the input of the ethics committee isoften the way reach a solution that is best for thepatient. The multidisciplinary approach of an in-stitutional ethics committee can explore a variety

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of acceptable approaches to resolution. The pa-tient, the home care nurse, and the family will ben-efit when problem solving becomes a group en-deavor rather than an individual challenge.

Beatrice B. Turkoski, PhD, RN, is an Associate Pro-fessor, Kent State University College of Nursing,Milwaukee, WI, and serves as Ethics Editor toHome Healthcare Nurse. Address for correspon-dence: P.O. Box 240103, Milwaukee, WI 53224(bturkoski@kent.edu).

REFERENCESAdministration on Aging (AoA). (1998). National elder

abuse incidence study. Retrieved March 13, 2003 fromhttp://www.aoa.gov/abuse/report/default.htm.

Beauchamp, T., & Childress, J. (1994). Principles of biomed-ical ethics (4th ed.). New York: Oxford University Press.

Botes, A. (2000). A comparison between the ethics ofjustice and the ethics of care. Journal of AdvancedNursing, 32(5), 1071-1075.

Fry, S., Cunningham, D., Fajkowski, J., McCormick-Gendzel,M., & Day, C. (2001). Evolution of a home health ethicscommittee. Home Healthcare Nurse, 19(9), 565-570.

Marshall, C., Benton D., & Brazier, J. (2000). Elder abuse.Geriatrics, 55(2), 42-49.

Shyu, Y. (2000). Patterns of caregiving when family care-givers face competing needs. Journal of AdvancedNursing, 31(1), 35-43.

Welfel, E., Danzinger, P., & Santora, S. (2000). Mandatedreporting of abuse/maltreatment of older adults: Aprimer for counselors. Journal of Counseling & Devel-opment, 78(3), 284-93.

ELDER ABUSE Reporting and InformationMedicaid Fraud Control Unit (MFCU)Each state attorney general’s office is mandated by federal law to have an MFCU that investigates Medicaid provider fraud and patient abuse and neglect in home care programsand home care services that participate in Medicaid.

Eldercare LocatorThe Eldercare Locator program is sponsored by the Administration on Aging (AoA). If youknow the address and ZIP code of an older person being abused, the Eldercare Locator can direct you to the proper agency in that area to report abuse (800) 677-1116.

Adult Protective ServicesIn many states Adult Protective Services is the state agency designated to investigate elderabuse. In other states it may be the state or county Area Agency on Aging, the Division or Department of Aging, or the Department of Social Services. Any county Agency on Aging Office can provide information about the appropriate place to report elder abuse in their area.

National Center on Elder Abuse (NCEA)This is a reliable resource for the public, for agencies, professionals, providers, and individualsfor information about elder abuse prevention, information, assistance, and elder abuse research: http://www.elderabusecenter.org/statistic/index.html