From http://www.nursingworld.org/ojin/ethicol/ethics_14.htm

Verb and Expression that are used to refer other people ideas are in red color.

ETHICAL CHALLENGES IN THE CARE OF ELDERLY PERSONS
Ruth Ludwick, PhD, RN, C Mary Cipriano Silva, PhD, RN, FAAN

Keywords: aged, aging, elderly, ethics, code of ethics
Ethical issues are central to any discussion or reflection on aging and health care. The authors of the OJIN topic, Health Care and the Aging Population: What Are Today's Challenges?, address a variety of topics including quality of life, long-term care planning, geriatric education, frail elder care, and successful aging behaviors. Imbedded in these topics are ethical issues that are relevant to nursing and/or health care. Thus, the focus of this column is to examine select ethical issues in these five articles on aging.
To frame our discussion, we will use the provisions of the 2001 American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements (referred hereafter as the Code). The Code represents the nursing profession’s public declaration of ethical duties and obligations and, as such, it serves as a basis for any discussion of ethics that involves nurses. Thus, the Code is applicable to us as we work with the aged, whether we make a home visit, administer a medication, answer a call light, develop a policy, or supervise a student. We begin the column with an overview of some of the ethical issues that are explicitly and implicitly discussed in each of the five articles and then examine how the ANA Code can inform and guide us with the ethical issues outlined.

Overview of Articles on Ethical Issues
The article by Bennett and Flaherty-Robb (2003) paints a broad picture of four issues affecting the health of older persons: lack of resources; scarcity of providers; financial barriers; and cultural barriers and biases. While there are many ethical problems that can be discussed within the context of these four issues, cultural biases stand out because nurses can personally examine these biases and change them in our daily practice. As the two preceding authors note in their article, stereotyping is common. Nurses are not immune to stereotyping and, thus, must examine their own beliefs and values about aging. Do nurses and the nursing profession have their own biases about aging? How do we react when we hear biases expressed by nurses or other health care workers or by families or by the elderly themselves? How much does age bias influence our decision to withhold treatment or informed consent?
In their article, Edlund, Lufkin, and Franklin (2003) address some of the problems related to long-term care in the US health care system. At first glance one may not consider the individual ethical implications imbedded in this topic. The article authors, however, point out the ethical duty nurses have to educate the public and at the same time keep themselves knowledgeable about long-term care. But are nurses as educated as they should be about long-term care? Have you heard nurses say, "I do not understand Medicare"? Have you heard acute care nurses publicly find fault with long-term care nurses or vice versa? Do you listen for and correct misperceptions such as, "Long-term care is nursing home care," or "Nursing homes are where people go when nobody wants you"?
Mion’s (2003) article addresses in depth the limited geriatric education of most nurses, even though these nurses will have some contact with geriatric populations. Even in pediatrics and maternity, where one assumes a younger population, we see in developed and in developing countries a rising number of grandparents who are primary caregivers for children. While the educational process may have fallen short, are nurses keeping up with the gerontological and ethical literature as it applies to the areas of nursing in which they work?
Young’s (2003) article outlines the issues related to care of frail elders in acute- and long-term care, examines subsequent challenges, and then suggests some innovative answers to their care. As Young discusses the challenge of resource allocation, she also notes ethical dilemmas. Specifically, she mentions end-of-life care and the decision to treat against the wishes of the dying person. In our professional or personal lives, have we found family members or other health care workers who persuaded us to prolong or start a treatment when it was expressly against the wishes of the dying person? Or have we been in a situation where we failed to ask in a timely manner what kind of care that dying persons want?
The last article by Hartman-Stein and Potkanowicz (2003) addresses the behavioral components of successful aging. Regarding this article, ethical questions can be raised about individual client responsibility and preference about lifestyle choices, but the ethical questions for nurses may not seem as apparent. For example, how often do we discuss with the elderly choices about exercise, religious beliefs, or cognitive activities? Do we routinely screen for depression, functional change, or cognition changes, or do we wait to do these screens until symptoms become problematic?
While each of the preceding five articles was addressed separately, in fact, the articles overlap. Both Bennett and Flaherty-Robb (2003) and Young (2003), for example, discuss cultural issues, but they do so from slightly different perspectives. Edlund, Lufkin and Franklin (2003) and Mion (2003) also address education but the issues are presented from varying standpoints. This overlap, while at first seeming contradictory, only helps to demonstrate the complexity of the issues. As you, the reader, reflect on the articles both individually and collectively, we hope you are challenged to think of the ethical issues that connect these articles. Now let us examine how the Code can be used for direction in reflection and practice.

The Provisions
The nine Provisions of the Code are rich in detail and broad enough to encompass the ethical issues discussed above. Each Provision of the Code can be used to guide our ethical reflection as we care for the aged, no matter where we work or what our practice level is. However, the four Provisions of the Code most relevant to this OJIN topic are: Provisions 1 (respect), 2 (commitment to patient), 5 (competence), and 8 (health promotion). These Provisions can be used to guide nurses in dealing with the specific issues discussed in the preceding five articles: (a) cultural barriers (Bennett & Flaherty-Robb, 2003; Young, 2003), (b) education (Edlund, Lufkin & Franklin, 2003; Mion, 2003), (c) end-of-life wishes (Young, 2003), and (d) lifestyle choices and responsibilities (Hartman-Stein & Potkanowicz, 2003).

Cultural Barriers
Examining one’s own beliefs and values, and one’s subsequent biases, is essential in examination of ethical issues. Our values and beliefs will impact on care provision, that is, on what care is provided, as well as when, where, why and how it is provided. Bennett and Flaherty-Robb (2003) note that in the American culture there is a "…strong elder bias…" (Issue 4: Cultural Values Do Not Give Priority to Providing Services and Support for Older Adults section, para 2 ). Let’s take an example of one bias and examine how it can impact our ethical view. If we stereotype the elderly as frail and, therefore, believe we must protect them, then we may not uphold Provision 1 of the Code (2001). Specifically the Code states, "The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems" (ANA, 2001, p. 7). While age is not specifically mentioned as an attribute, it is implied and thus this principle can give us guidance on issues dealing with older people.
The principle of respect for persons, as cited in Provision 1 of the Code (2001), seems easy to understand at an intuitive level. It implies that as nurses we value an individual or group’s beliefs and wishes and consider those when acting as a professional nurse. But it may be harder to follow in practice if one believes that frail older persons must be protected. For example, conflicts may arise between what the patient needs to know to be informed and what you, other health care workers, or family members believe the person should be told. Thus, ethical issues may result around truth-telling and/or informed consent, and it is vital for each of us to examine our biases and stereotypes. To that end we have provided some websites that examine myths related to aging:
Myths about Aging www.go60.com/myths.htm
Exploding Aging Myths www.prairiepublic.org/features/healthworks/Aging/myth.htm
Test Your Knowledge www.webster.edu/~woolflm/myth.html

Education
Several OJIN topic authors address education (e.g., Edlund, Lufkin & Franklin, 2003) and the lack of gerontological content in nursing curricula (e.g., Mion, 2003). Staying current in one’s profession is an ethical duty to the constituency the profession serves. While education reforms may be advocated and in progress in nursing programs in the US (e.g., see the website of the John A. Hartford Foundation Institute of Geriatric Nursing) and across other countries (e.g., see Primomo, 2000) it is vital that we each examine our individual needs regarding education and, in particular, gerontological education. Specifically Provision 5 of the Code (2001) addresses competence and professional growth. The Code states, "The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth" (ANA, 2001, p. 18).
Actions to consider in relation to competence and professional growth might include a range of activities. Some actions such as formal education (e.g., continuing education, formal classes, degree work) are perhaps more obvious than demonstrating competence (e.g., certification, clinical ladders) or personal growth (e.g., reading books and journals, volunteering in or developing programs that provide services to the elderly). To examine and reflect on your own practice, consider visiting the John A. Hartford Foundation Institute of Geriatric Nursing and click on the link on the left column of the website that relates to your role as a nurse (e.g., educator, practice nurse) to see specific suggestions for helping with your education and competence.

End-of-Life Wishes
Young (2003) raises thought-provoking questions in her article about weighing public and individual responsibility in resource allocation. She raises a number of issues about public policy related to end of life. Although when united nurses can influence and set policy related to end-of-life issues, the majority of nurses examine end-of-life issues at the personal level. At the bedside, it is not uncommon to hear statements like "We can’t just let mom die," or "Mom would not have wanted to live like this." When families of different dying persons voice these statements and the statements are reflective of the dying person’s wishes and also within the scope of nursing practice, there is no conflict. But members of the same family often express conflicting statements, or perhaps no one has asked the dying person what is wanted related to end-of-life care. Often complicating these scenarios are the respective opinions that every other health care member involved may hold. The nurse provider may feel "caught in the middle" and often without the resource of an ethics committee. In these types of conflicts, how can autonomy and self-determination of the competent dying person be upheld and preserved?
Both Provision 1(previously discussed) and Provision 2 of the Code (2001) can guide nurses with these difficult dilemmas. Specifically, Provision 2 states, "The nurse’s primary commitment is to the patient, whether an individual, family, group or community" (ANA, p. 9). In the conflicting statements given above, remember that if you are the nurse caring for the dying person, your first duty is to that person. Secondly, your duty is to the family, that is, to help the family understand the wishes of the dying person. Provision 1 discusses the right to self-determination and Provision 1.4 expressly states, "The nurse supports patient self-determination by participating in discussions with surrogates, providing guidance and referral to other resources as necessary, and identifying and addressing problems in the decision-making process" (ANA, p. 9).
How can we help families to respect and support the dying person’s wishes? As patient advocates we can advise, foster, and facilitate early discussions about end-of-life issues, thus helping individuals make informed decisions. Early discussions also help family and significant others to discuss beliefs and values with the elderly person when death becomes more imminent. Suggested resources for nurses to use with families can be found at the following websites:
End-of-Life Care (an international journal of leaders in end-of-life care) www2.edc.org/lastacts/archives/archivesJan99/default.asp
Last Acts (National Coalition To Improve Care and Caring Near the End of Life) www.lastacts.org/

Lifestyle Choices and Responsibilities
The article by Hartman-Stein and Potkanowicz (2003) addresses the behavioral components of successful aging, with particular emphasis on starting early to assure healthy aging. At a practice level, however, it is not uncommon for nurses to voice such biases as, "The elderly have made lifestyle choices; I am not going to change their views," and "If you live to be 80, you deserve to be able to do what you want." These commonly voiced beliefs, which may be based on stereotypes, only make health promotion harder to implement. Health promotion is seen as easier to set aside than other nursing care for a number of reasons: technology focus of the health care system, nursing shortage, mechanisms for implementing health promotion may not be in place, and the results from health promotion are not easy to document.
However, Provision 8 of the Code (2001) clearly identifies nurses’ responsibility for health promotion: "The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs" (ANA, p. 23). Yet the elderly are often forgotten in health promotion. Young (2003) points out that despite growing stress placed on health promotion, a large number of elderly have any number of chronic conditions that are linked to lifestyle choices that do not include positive health promotion activities.
Nursing has been at the forefront in health care in commitment to health promotion. The OJIN topic titled Nursing Around the World (2000) features articles form nurses in several countries where health promotion is emphasized. Yet, the question remains: What can we do individually and collectively to promote health among the elderly? In 1997, the ANA drafted a Position Statement entitled "Promotion and Disease Prevention" that is available at http://www.nursingworld.org/readroom/position/social/scprmo.htm. At the site are listed eight strategies for health promotion and disease prevention. To learn more about health promotion, visit the following sites and think about the ethical context:
Put Prevention into Practice (PPIP) Agency for Healthcare Research and Quality www.ahrq.gov/clinic/ppipix.htm
Office of Disease Prevention and Health Promotion http://odphp.osophs.dhhs.gov/
Daly M. and Katzel L. Health promotion and disease prevention in the elderly. Retrieved August 3, 2003 from : http://hora.cpmc.columbia.edu/dept/dental/Dental_Educational_Software/

Summary
In summary, a short review of each article in the topic, Health Care and Aging Population: What are the Challenges?, and possible ethical issues (either implicitly or explicitly discussed) were reviewed. Although each article was examined individually, there was overlap in the articles. The Code (2001) was used to examine the nurse’s ethical duties to the elderly regarding cultural barriers, education, respecting end-of-life wishes, and lifestyle choices and responsibilities.

AUTHORS
Ruth Ludwick, PhD, RN, C e-mail: ojinethics@kent.edu
Ruth Ludwick, RN, PhD, C, is a Professor at Kent State University, College of Nursing (CON). She is an Associate Editor and a member of the founding editorial board of the Online Journal of Issues in Nursing (OJIN). She serves as coordinator for the OJIN Ethics Column and coordinator of the links for each topic. Ruth teaches across the curriculum. She is widely published and presents nationally and internationally on research related to research, gerontology, college teaching and online work. She is actively involved with research with colleagues in N. Ireland, Australia, and England related to the factorial survey method.
Mary Silva, PhD, RN, FAAN e-mail: msilva@gmu.edu
Mary Silva, RN, PhD, FAAN, received her BSN and MS from the Ohio State University and her PhD from the University of Maryland. She also completed post-doctoral study at Georgetown University in health care ethics. Since 1974, she has been a prolific writer about health care ethics in general and ethics in nursing administration in particular. Recently, she was a member of the ANA Code of Ethics Project Task Force. The Task Force, along with ANA staff guidance, wrote the 2001 Code of Ethics for Nurses with Interpretive Statements, which won an AJN "Book of the Year Award." Dr. Silva is a Professor of Nursing at George Mason University in Fairfax, VA.

REFERENCES
American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing. Retrieved August 3, 2003, from www.nursingworld.org/ethics/code/ethicscode150.htm
Bennett, J., & Flaherty-Robb, M. (2003). Issues affecting the health of older citizens: Meeting the challenge. Online Journal of Issues in Nursing, 8(2), Article 1. Retrieved August 3, 2003, from www.nursingworld.org/ojin/topic21/tpc21_1.htm
Edlund, B., Lufkin, S., & Franklin, B. (2003). Long-term care planning for baby boomers: Addressing an uncertain future. Online Journal of Issues in Nursing, 8(2), Article 2. Retrieved August 3, 2003, from www.nursingworld.org/ojin/topic21/tpc21_2.htm
Hartman-Stein, P., & Potkanowicz, E. (2003). Behavioral determinants of healthy aging: Good news for the baby boomer generation. Online Journal of Issues in Nursing, 8(2), Article 5. Retrieved August 3, 2003, from www.nursingworld.org/ojin/topic21/tpc21_5.htm
Mion, L. (2003). Care provision for older adults: Who will provide? Online Journal of Issues in Nursing, 8(2), Article 3. Retrieved August 3, 2003, from www.nursingworld.org/ojin/topic21/tpc21_3.htm
Young, H. (2003). Challenges and solutions for care of frail older adults. Online Journal of Issues in Nursing, 8(2), Article 4. Retrieved August 3, 2003, from www.nursingworld.org/ojin/topic21/tpc21_4.htm