NOTRE DAME OF MARBEL UNIVERSITY

Alunan Avenue, City of Koronadal

College of Arts and Sciences
Nursing Department

…an institution that cares for

the environment and humanity

Ethico-Legal Consideration

Communicating with Older Persons

Geriatric Health Care Team

 Learning Outcomes:
At the end of the lesson; the
students can:
1.Identify the Ethical principles,
dilemmas and practices in the
care of the elderly.
2.Describe the communication
skills and techniques use as
part of the healing process.
 Learning Outcomes:
At the end of the lesson; the
students can:
3. Explain the roles of the
Geriatric health team in
holistic care.
 Ethics is a fundamental part of geriatrics that refers to a framework or
guideline for determining what is morally good or bad. Ethical problems
arise when there is conflict about what is the “right” thing to do.
Being able to communicate effectively is one of the most
important life skills. Those with good interpersonal skills are strong verbal
and non-verbal communicators and are often considered to be “good with
people.”
Therefore, knowing what is the right thing to do and how to properly
communicate not only to the patient but also to the entire health care
team allows nurses to deliver safe and quality care.
T H E L I V E D E X P E R I E N C E
When I was growing up life was hard. We were so poor we

couldn’t do much but to hold on tight. When I was lucky I could

get work plowing a field and make $1.00 an acre. You work hard,
and you make do. There were not such things as going to a doctor
or a hospital, you just did the best you could do and pray you
don’t get sick. Then when I turned 65 I got a little check from the
government and a red, white, and blue insurance card. The check
isn’t much, only about $564 a month, but you know I just consider
myself blessed and better off than ever before. And now I don’t
worry about my health, I will be taken care of .
Aida, age 74
Ethics - Legal
Considerations

in the Care of

Older Adult
The key legal considerations center on

- consent
- standard of care
- supervision
Care for the aged resembles healthcare
in some respects:

- respect for autonomy

- beneficence (acting for the good of the patient)
- nonmaleficence (avoiding harm)
- justice (treating people alike)
A. Laws affecting Senior Citizens / Older Persons
(RA 7432, RA 9257, RA 9994)
Expanded Senior Citizens Act of 2010
• h t t p s ://www. o ffi cia lg azette.go v.p h/201 0/02/15 /repu bl ic -a ct-no-9 994 /

REPUBLIC ACT NO. 9994

• An act granting additional benefits and privileges to senior

citizens, further amending republic act no. 7432, as amended,
otherwise known as “an act to maximize the contribution of
senior citizens to nation building, grant benefits and special
privileges and for other purposes”
A. Laws affecting Senior Citizens / Older Persons
National policy on Older People

REPUBLIC ACT NO. 334

• The Accessibility Law of 1982 provides for a minimum

requirements and standards to make buildings, facilities and
utilities for public use accessible to persons with disability,
including older persons who are confined to wheelchairs and
those who have difficulty in walking or climbing stairs.
A. Laws affecting Senior Citizens / Older Persons
An Act Establishing a Senior Citizens Center in all
Cities

REPUBLIC ACT NO. 7876

• “Includes municipalities in the Philippines and Appropriating

Funds Therefore” provides for establishment of Senior Citizens
Centers to cater to older persons’ socialization and interaction
need as well as to serve as a venue for the conduct of other
meaningful activities.
A. Laws affecting Senior Citizens / Older Persons
Presidential Proclamations and Executive Orders

Presidential Proclamation No.470 Series of 1994, declaring the

first Week of October of every year as “Elderly Filipino Week.”

Executive Order No.105, Series of 2003, approved and directed the

implementation of the program providing for group homes and
foster homes for neglected, abandoned, abused, detached and
poor older persons and persons with disabilities.
B. Medications of Older Adults

• Polypharmacy - the use of multiple medications. There is no

standardized threshold to define what constitutes “multiple
medications”; however, a threshold of at least five medications is
commonly accepted.
C. Ethical Principles / Dilemmas
Legal Issues in Gerontological Nursing

Basic knowledge of the most common legal issues that may

arise when working with older adults is as important as the
financial issues. Legal concerns are most often related to an
individual’s ability to make health care decisions and consent to
treatment or research.
C. Ethical Principles / Dilemmas

Competence and capacity are interchangeable legal terms used

to indicate the level of a person’s ability to make decisions.

- includes the ability to understand the consequences of one’s

actions and choices.

- ability is presumed unless there is clear evidence indicating that

the person cannot understand the information needed to make
decisions.
C. Ethical Principles / Dilemmas

Power of attorney (POA) is a legal document in which one person

designates another person (e.g., family member, friend) to act on
his or her behalf.

Guardians and conservators are individuals, agencies, or

corporations that have been appointed by the court to have care,
custody, and control of a disabled person and manage his or her
personal or financial affairs (or both) when the person has been
found (adjudicated) to lack capacity.
C. Ethical Principles / Dilemmas

Elder Mistreatment and Neglect

A person in need of the assistance of others is at risk for harm and

injury at the hands of a frustrated, angry, fraudulent, careless, or
disturbed caregiver. Mistreatment of older frail and vulnerable
adults is found in all socioeconomic, racial, and ethnic groups.
D. Long-Term Care
- involves a variety of services designed to meet a person's health or personal
care needs during a short or long period of time. These services help people
live as independently and safely as possible when they can no longer perform
everyday activities on their own.

• Long-term care is provided in different places by different caregivers,

depending on a person's needs. Most long-term care is provided at home by
unpaid family members and friends. It can also be given in a facility such as
a nursing home or in the community, for example, in an adult day care
center.
E. Palliative Care
- is specialized medical care for people living with a serious illness. This type
of care is focused on providing relief from the symptoms and stress of the
illness. The goal is to improve quality of life for both the elderly and the family.

• provided by a specially-trained team of doctors, nurses and other specialists

who work together with a patient’s other doctors to provide an extra layer of
support. Palliative care is based on the needs of the patient, not on the
patient’s prognosis. It is appropriate at any age and at any stage in a serious
illness, and it can be provided along with curative treatment.
F. Advance Directive
- is a legal document
- tells the doctor and family what kind of medical care an old
person wants to have if he/she can’t tell them him/herself.

This could happen if the elderly is:

in a coma
seriously injured
terminally ill
have severe dementia
F. Advance Directive

A Do Not Resuscitate (DNR) order can also be part of

an advance directive. Hospital staff try to help any patient
whose heart has stopped or who has stopped breathing.
They do this with cardiopulmonary resuscitation (CPR). A
DNR is a request not to have CPR if the heart stops or the
patient stops breathing. The doctor will put the DNR order
in the medical chart.
G. End of Life Care
Loss, dying, and death are universal, incontestable events of the human
experience. Some loss is associated with the normal changes with aging, such
as the loss of flexibility in the joints. Some is related to the normal changes in
everyday life and life transitions, such as moving and retirement.

• One goal of intervention is to assist the individual (or family) in attaining a

healthy adjustment to the loss experience and reestablishing equilibrium.
Memories are reframed so that they can account for the loss without
diminishing the value of that which has been lost thus minimizing the risk for
complicated grief.
G. End of Life Care
• When elders are in crisis, begin with the gentle establishment of rapport.
Nurses introduce themselves, explain the nature of their roles (e.g., charge
nurse, staff nurse, medication nurse) and the time available. Provide support
and a safe environment and ensure that basic needs , such as meals, are met.

• The nurse can soften the despair by fostering reasonable hope , such as,
“You will make it through this time, one moment at a time, and I will be here to
help.” Nurses observe for functional disruption and offer support and direction.
They may have to help the family figure out what has to be done immediately
and find ways to do it.
G. End of Life Care

• As grievers search for meaning, nurses may need help in finding

what they are looking for if this is possible. Sometimes it is
information about a disease, a situation, or a person. Sometimes it
is a spiritual search and help in finding a source of comfort such as
a priest, rabbi, or medicine person or a place of peace, such as the
chapel or mosque.
H. Spirituality among Older Persons

Spirituality is as a “quality of a person derived from the social

and cultural environment that involves faith, a search for meaning,
a sense of connection with others, and a transcendence of self,
resulting in a sense of inner peace and well-being.”
The spiritual aspect of people’s lives transcends the physical and
psychosocial to reach the deepest individual capacity for love,
hope, and meaning.
H. Spirituality among Older Persons
• As people age and move closer to death, spirituality may become more important.
Declining physical health, loss of loved ones, and a realization that life’s end may be
near often challenge older people to reflect on the meaning of their lives. Spiritual
belief and practices often play a central role in helping older adults cope with life
challenges and are a strength in the lives of older adults.

• Distinguishing between religion and spirituality is a concern for many health

professionals. Religious beliefs and participation in religious obligations and rites are
often the avenues of spiritual expression, but they are not necessarily
interchangeable. “Religion can be described as a social institution that unites people
in a faith in God, a higher power, and in common rituals and worshipful acts. Each
religion involves a particular set of beliefs
Communicating
with Older
Persons
A. Information Sharing

• Privacy refers to the right of an individual to keep his or

her health information private.

• Confidentiality refers to the duty of anyone entrusted

with health information to keep that information private.
B. Formal or Therapeutic Communication
B. Formal or Therapeutic Communication

• Attentive, Active Listening is an essential part of communication. It is far

more than hearing and simply remaining silent while listening to words.
Active attentive listening is not a passive activity; it entails the nurse's
hearing, processing and purposefully comprehending the client's
words, as well as processing these words in the context of the
client's situation and the nonverbal communication that is sent by the
client as they are verbally expressing some message to the nurse.
B. Formal or Therapeutic Communication

• Silence is a purposeful active process rather than a passive process.

Senders and receivers of the message take advantage of brief pauses of
silence to think about and reflect on the full meaning of received
message and to contemplate and reflect on how to respond to the
sent message with feedback. Silence is a therapeutic communication
technique that is also very helpful when the nurse wants to give the client
ample time to fully and openly discuss their feelings, opinions and
beliefs, however, prolonged silence may be interpreted by the client as a
lack of interest on the part of the nurse so silence, in order to remain
therapeutic, must be of an appropriate duration so that it does not
adversely affect the client and the therapeutic nurse-client relationship.
B. Formal or Therapeutic Communication

• Focusing with the client is a therapeutic communication technique used by nurses,

and other members of the health care team, that facilitates the client 's abilities to
focus on and pay attention to the matters at hand, which should reflect the
client 's priorities. Some clients may use the nurse's presence to talk about things
not even related to their health care and their health care problems. For example,
they may want to chat about their extended family and their accomplishments at the
same time that the nurse has to educate the client about their plan of care. Focusing
on the subject at hand decreases the risk of having these kinds of distractions
impair the therapeutic communication process. For example, the nurse may say,
"Mrs. Jones, your family is very interesting and successful. Thank you for sharing this
information with me. Now, let 's discuss your diabetes and the insulin that you will be
taking after you leave the hospital".
B. Formal or Therapeutic Communication

• Using Open Ended Questions elicits more and fuller information than a closed
ended question that requires more than a simple yes or no answer. This
therapeutic communication technique is particularly useful when the nurse
wants fuller and deeper information from the client and when the nurse is
facilitating the client's full and free ventilation and expressions of their own
feelings and beliefs. Closed ended questions are also useful particularly
when the client is not able to, for one reason or another, formulate more
complete feedback and communication to the nurse. For example, closed
ended questions are useful when the client is cognitively impaired or they
are on mechanical ventilation with intubation and not able to speak with the
nurse and others.
B. Formal or Therapeutic Communication

• Clarification - Messages are often clarified and validated with clients in

order for the nurse to insure that the nurse has received and interpreted
the complete and correct message without any errors, without any bias
and without any false assumptions. Specific clarification techniques
include exploring, paraphrasing, reflecting and restating, which will be
discussed below. A possible question that the nurse may ask the client to
clarify a message could be "Am I correct that you told me that you plan
on having home health care after your discharge?" or "You appear upset.
Would you like to talk about it?' when the client appears upset with their
nonverbal facial cues.
B. Formal or Therapeutic Communication

• Exploring in contrast to invasive and non therapeutic

probing, is using techniques that encourage the client
to provide more details and information about a
particular topic or health care problem.
B. Formal or Therapeutic Communication

• Paraphrasing is used to clarify a client's message, is used

by the nurse to rephrase a client's comment or
question in a manner that is similar to what the nurse
thinks that they have heard and understood. For
example, a nurse may paraphrase a client statement
such as "I am too tired to even think" with, "Did you
mean that you are too tired now to continue with this
education?"
B. Formal or Therapeutic Communication

• Restating is done to clarify the client's message by

repeating the same statement back to the client. For
example, when a client says, "I am ready to do some
walking" and the nurse says, "Did I hear you say that
you are now ready to do some walking?"
B. Formal or Therapeutic Communication

• Reflection a technique that reflects and mirrors what the nurse

believes the client's feelings to be underneath the words. It
mirrors, or reflects, the patient's feelings, not words, back to
the client so that the client's feelings can be further explored
and expressed by the patient. For example, when a client
appears to be angry and upset, the nurse may state, "You
seem a little angry today. Would you like to talk about it?".
B. Formal or Therapeutic Communication

• Providing Leads to the Patient enables the client to continue

discussing things with the nurse and it also facilitates the
client's beginning a new discussion that is focused on a
particular thing. For example, the nurse may say, "Tell me
about your concerns relating to your new medications".
Hopefully, the client will take this lead and begin a discussion
about their new medications and their concerns relating to
them with the nurse.
B. Formal or Therapeutic Communication

• Summarizing is a highly useful therapeutic communication technique

that sums up the primary and main points that were discussed as well as
the conclusion of the discussion that was mutually decided up. For
example, a nurse who is educating the client and family members about
diabetes management and the interactions of diabetic medications,
exercise, diet and other factors may summarize this discussion with a
summarizing statement such as, "During our discussion today, we have
discussed the roles of diabetic medications, exercise, diet and other
factors as they interact with each other and how these interactions
impact on the successful management of diabetes."
B. Formal or Therapeutic Communication

• Recognition, Acknowledgment and Acceptance of the client and their

thoughts which are conveyed during communication are
therapeutic communication techniques and strategies that
give the nurse the opportunity to let the client know that you
are interested in them and respectful of them and their
thoughts It also allows the client to recognize that the nurse is
open, honest and without any bias or judgements. The nurse
accepts the client regardless of their thoughts and words.
B. Formal or Therapeutic Communication

• Offering of Self - therapeutic communication process and

the therapeutic nurse-client relationship must be
based on the nurse's willing and unconditional
offering of self and their time to the client and their
needs with only limited self disclosure by the nurse
that directly assists the client with meeting their
needs.
C. Informal or Social Communication

• Informal communications include speaking to a person

about the weather, writing an email about your holiday,
sending a birthday card or talking to someone at the
grocery shop. Informal communications can also be
gestures (with no words). Informal communication in the
workplace is often called 'the grapevine'.
D. Non-verbal Communication

✓ Facial expressions - the human face is extremely

expressive, able to convey countless emotions without
saying a word
✓ Body movement and posture
✓ Gestures
✓ Eye contact
✓ Touch
E. Acceptance, Dignity and Respect in Communication

Treat patients with Dignity

✓ Listen to his/her concerns.

✓ Ask for opinions and let him/her know they are important to you.
✓ Involve in as many decisions as possible.
✓ Include in the conversation. Don't talk about him/her as though
he's not there.
✓ Speak to him/her as an adult, even if you're not sure how much
he understands.
F. Barriers to Communication

• Challenging is forcing the client to defend and justify their

opinions, beliefs, and feelings. Challenging shows a lack of
respect for the client and a lack of acceptance of the client as
a unique being who has, and is entitled to, their own beliefs
and opinions. The client has valid feelings that should never
be challenged by the nurse.
F. Barriers to Communication

• Probing is also not therapeutic. It is invasive, uncomfortable for

most clients, and a threat to the client's right to privacy and
confidentiality. Probing the client with questions that are not
relevant to their health care and health related concerns is
never appropriate. It may satisfy the nurse's curiosity but it is
NOT at all helpful to the client and addressing the client's
needs.
F. Barriers to Communication

• Changing the Subject serves only the needs of the nurse and not
the client, therefore, it too is not acceptable in nursing
practice. People, including nurses, change the subject when
they are too uncomfortable and uneasy about continuing the
conversation. The conversation has become too stressful for
the nurse. This is not an option. Nurses must identify their
own feelings and cope with them before they enter into
therapeutic conversations and relationships with clients.
F. Barriers to Communication

• Defensiveness occurs when the nurse feels the need to defend

themselves, their actions, their employers or others for their
failures and shortcomings. Again, this technique fulfils the
needs of the nurse rather than the client and, as such, it is not
therapeutic.
F. Barriers to Communication

• False Reassurances like trite comments and giving clients every

day advice, are not at all therapeutic. False assurances and
reassurances such as "Don't worry, you are in good hands" and
"Everything will be fine" are examples of false reassurances
that will certainly be a conversation stopper that will lead to
client anxiety and the client's unwillingness to share their true
thoughts and fears to the nurse in the future. These effects
are detrimental to the client and their wellbeing as well as the
therapeutic nurse-client interactions at the present time and
also in the future.
F. Barriers to Communication

• Disagreeing with clients is also not therapeutic or

acceptable. The nurse can attempt to correct
misinformation in a therapeutic manner but they
should never disagree or argue with the client, their
feelings and/or opinions.
F. Barriers to Communication

• Judgments place a positive or negative value on the

client and their messages. The therapeutic nurse-client
relationship must be, at all times, nonjudgmental,
open and honest.
F. Barriers to Communication

• Rejection and Minimization

- Rejection of the client and any minimization and

rejection of their expressions of feelings and thoughts
are also not at all acceptable in the therapeutic nurse -
client relationship.
F. Barriers to Communication

• Stereotyping is a barrier to effective communication and,

in fact, it is a barrier to all thought and interpersonal
relationships. Stereotyping involves generalized
thoughts and words that are not at all based on the
individuality and uniqueness of the individual.
Geriatric
Health
Care Team
A. Gerontologist / Geriatrician

• Gerontologists are responsible for educating other health

professionals, community practitioners, as well as the community
at large about the process of aging and how to age well by giving
informative presentations, publishing books and articles about
aging and health. A geriatrician is a doctor who specializes in care of
the elderly and the diseases that affect them. The approach tends to
be holistic and involves a multidisciplinary team.
The geriatrician concentrates on managing the medical conditions
affecting the patient.
B. Nurse Gerontologist

• A geriatric nurse or gerontological nurse helps care

for aging and elderly individuals. They are trained to be
able perform traditional nursing duties, yet they also
have special training that helps them better understand
the special needs of many elderly people.
C. Occupational Therapists

• Occupational Therapists treat injured, ill, or disabled

patients through the therapeutic use of everyday
activities. They help these patients develop, recover,
improve, as well as maintain the skills needed for daily
living and working.
D. Physical Therapists

• Physical Therapists evaluate and record a patient's

progress. Help the injured or ill people improve movement
and manage pain. They are often an important part of
preventive care, rehabilitation, and treatment for patients
with chronic conditions, illnesses, or injuries.
E. Speech and Language Therapists (SLT)

• Speech and Language Therapists (SLT) are highly

trained professionals who assess and treat children and
adults who are having difficulties with speech or
language, as well as problems with communication,
eating, drinking, and swallowing.
F. Case Manager

Case Manager are registered nurses tasked with the

evaluation and implementation of health care plans for
individual patients. They are concerned with providing
effective and efficient medical care while managing the costs
of treatment. Assess new patients. Update and revise patient
health care plans as needed.
G. Family / Significant others
H. Nursing and Interdisciplinary Care; Conference Team

• Interdisciplinary Care Team (ICT) is a team of

healthcare professionals from different professional
disciplines who work together to manage the physical,
psychological and spiritual needs of the patient.
Whenever possible the patient and the patient's family
should be part of the team.
 Do you have any
questions from our
lesson today?