A passive neglect report was made to Metropolitan Family Services (MFS) Adult Protection Services (APS) on accounts of a client who will go by Mr. H. Mr. H is an 80-year-old man who was brought to the hospital after his neighbor called the paramedics. The paramedics report finding Mr. H laying on the bathroom floor, unable to get up. Mr. H is unable to give an account of how long he was on the floor; first responders estimate somewhere between 48-72 hours.
A social worker from MFS APS was assigned to the case to conduct an investigation. Mr. H. is a single man who shares his apartment with his child, Mark. Mark acts as Mr. H’s primary caretaker and was not in the apartment when the paramedics arrived. According to numerous neighbors, Mr. H’s health has been in steady decline over the past year. The social worker stated that the neighbors have found Mr. H yelling at night for food, and on a few occasions have found Mr. H walking around the corridor lost and confused. The neighbors are very worried about Mark’s ability to care for Mr. H. Many neighbors stated that Mark goes long periods of time without coming home. The social worker also spoke to the landlord, and he stated that Mark comes home drunk and becomes aggressive under alcohol. The social worker conducted a visit to Mr. H’s home and stated that Mr. H’s apartment is filthy, there is no food in the house, and Mr. H medication bottles are empty.
According to the doctor, Mr. H appears to be alert but disoriented to place and time; however, he is stable. He is moderately dehydrated and appears to be malnourished. His arms are covered in lesions, which are infected, and he has an ulcer on his head from the fall. His personal hygiene is extremely poor; his legs are covered in dried feces and he smells strongly of urine. Mr. H has a history of multiple falls in the past. The doctor stated that Mr. H must stay hospitalized and treated for his wounds, or they could become infected and lead to severe health complications.
After close moderation, Mr. H’s continues to be disoriented and his wounds appear to be getting worse. Mark arrives and after visiting briefly with Mr. H, Mark announces he would like to take Mr. H home. The doctor explained to Mark that Mr. H requires medical care and that discharging him now would be against his medical best interest and could put him in great danger. Mark is persistent: he states that he acts as Mr. H’s power of attorney (POA) for personal care and finances, and that he is taking him home. Mark states that he has “stuff to do at home” and has no time to look over his father at a hospital; he goes on about medical costs and states that medical expenses are unnecessary. Mark makes it clear that he will take his father home and tells the doctor that Mr. H will be fine.
Autonomy, or the right to make free and informed choices, is a given right to older adults who are deemed as alert, aware and oriented. Assessing capacity is extremely important in cases of suspected or confirmed elder abuse and neglect: this is especially true in health care. A patient who has capacity has the freedom to make a decision to remain in an abusive situation, or take risks, that an incapable patient may not. Although Mr. H was disoriented, he did not receive a proper mental assessment to determine a legal diagnosis. This becomes an ethical dilemma when the hospital states for Mr. H to stay, Mark states for Mr. H to go home, and Mr. H’s decision to remain in the hospital remains uncertain.
Causation and who can solve the dilemma
The cause for Mr. H’s neglect is Mark’s inability to adequately care for him. Since the case arrived to MFS APS, it was assigned to a social worker to ensure that the client’s rights are protected. The social worker for Mr. H may experience uncertainty in deciding how to negotiate the dual obligations to respect patient autonomy and the professional duty to promote patient wellbeing. The social worker is liable to take the necessary steps in order to protect the client’s best interest. The social worker will need to confirm that Mark is legally Mr. H’s POA and legal guardian. This can be done through paperwork. Next, the social worker must determine whether abuse occurred. If the case is substantiated, legal action will be taken against Mark in order to remove him as a legal guardian and POA. Then, the social worker can act with or on behalf of Mr. H to ensure that his health is properly taken care of.
Short and long term consequences & benefits
The social worker and the clinical staff may struggle with whether or not it is right to permit an older adult to return to an abusive situation, despite the risk involved. The long term consequence of allowing Mark to take Mr. H home despite clinical advice is that the client can be subject future abuse and even death. The short term consequence of Mr. H returning home is that Mr. H’s health will progressively decline. Mark, the alleged abuser, will benefit from taking his father home because it will “save him money” and allow him extra time to perform other activities.
Gain or Losses
Mr. H is the main individual that can either gain or lose from this course of action. Mr. H is the one who is currently at the hospital with multiple health problems caused by the neglect from the alleged abuser. Although Mr. H is alert, he is still disoriented to place and time which makes him vulnerable. Mr. H needs medical attention due to his wounds that are progressively getting worse and can lead to death. Mr. H can gain from medical attention and advance his health, or he could be discharge and go back to his alleged abuser while placing him back in a dangerous environment.
Mr. H requires long term care and the physician and social worker should attempt to keep him in hospital until his condition has stabilized and a “safe” discharge can be confirmed. Mark indicated he wants to take Mr. H home but Mr. H needs to be engaged in this decision deeming he is alert. To respect Mr. H’s autonomy, he is legally entitled to leave; however, any refusal of treatment or would have to cautiously documented. In the case of any release, a harm reduction approach to care for Mr. H should be provided by a social worker in order minimize any potential risk.
Under the National Association of Social Workers (NASW) code of ethics, section 1.02 Self determination states that “…. respect and promote the right of client self determination and assist clients in their efforts to identify and clarify their goals…” (Code of Ethics, 2019). All clients who have decision-making capacity have the right to make free and informed choices. This is especially true about older adults in health care. It is important to assess a client’s capacity in cases of suspected or substantiated elder abuse and neglect. Informed consent is required in order to agree or deny to resources, interventions and assistance. Furthermore, a patient who has capacity has the freedom to make a decision to remain in an abusive situation, or take risks, where as a social worker may act on behalf of the client’s best interest.
Section 1.07 under the NASW code of ethics speaks about privacy and confidentiality. Social workers and community care agencies are responsible for deciding when and how to share confidential personal health information among multiple parties should be made with due consideration of the patient’s right to privacy and confidentiality. There may also be concern about who in the treating-team should be informed of suspected abuse for fear of creating prejudice towards the alleged abuser before the claim is substantiated.
One dilemma that can arise is that if abuse is substantiated the social worker must take the necessary steps to reassign a new power of attorney and caregiver for Mr. H. This can lead to be placed with family member which he does not have an established rapport with, or who can potentially be another abuser. Another factor to consider is that Mr. H would have to be placed in a hospice home away from Mark, or Mark would have to leave the apartment where Mr. H resides- leaving Mr. H to live alone or with another family member. Either situation may leave Mr. H in a vulnerable predicament.
Upon arriving to the emergency room, the social worker who was assigned to Mr. H immediately assessed him through the state mini mental health evaluation (MME). Mr. H was found unable to hold the capacity to make decisions for himself. The social worker acted on the client’s best interest regardless of Mark being the POA and legal care giver. The social worker found major evidence that led to the substantiation. The social worker had to go through extensive documentation in order to assign a new power of attorney and legal care guardian. Mark was successfully removed from his rights and Mr. H’s niece volunteered to move with the client in order to properly care for him. The social worker offered additional services for Mr. H in order to improve his day-to-day life. Mr. H was provided with meals on wheels, homecare services and was additionally provided with a harm reduction plan.
- Code of Ethics. (2019). National Association of Social Workers, retrieved from https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English