Vulnerable older people at risk at end of life
A guest blog post by Dr Kelly Purser and Associate Professor Tina Cockburn, Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology
The escalating, and often hidden, problem of elder abuse is chief amongst the challenges confronting Australia’s ageing population. It is a challenge not only for older people but also for other key stakeholders including, for example, health professionals, lawyers, government, policy makers and social workers (Purser et al, 2018).
Compounding the problems are the definitional and prevalence uncertainties in this area. At what age a person becomes ‘older’ is unclear. Definitions range from fifty years and over, to sixty-five years and over. ‘Older’ most commonly refers to people aged sixty years and over (United Nations, 2015) or sixty-five years and over (Australian Institute of Health and Welfare, 2017). For Indigenous Australians ‘older’ is generally categorised as 50 years and over.
The precise scope of the term ‘elder abuse’ is also elusive. A generally accepted definition is “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (WHO, 2002, p. 3). It can include financial, psychological, emotional, physical, sexual, abandonment, neglect, and/or serious loss of dignity and respect, with financial and emotional abuse being the most common (WHO, 2017). Definitional confusion contributes to challenges in determining prevalence rates (ALRC, 2017). No Australia-wide prevalence study has occurred - although calls for one have been made (ALRC, 2017).
Further contributing to the difficulty in ascertaining the extent of elder abuse is its hidden nature – and suspected underreporting. However, despite the lack of comprehensive data, approximately 1 in 6 elders are suspected to have experienced some form of abuse in the last year (Yon et al., 2017). Particular issues may present in rural and remote communities as well given that people can be more geographically isolated and/or have difficulties in accessing health care, and other relevant professionals and services (ALRC, 2017).
The abuser can often be a family member or carer, particularly an adult child or children. This can lead to tension-filled family relationships as well as provide further sources of intense stress and anxiety for the older person.
End of life situations can present a particularly challenging time for older people, especially vulnerable older people. In considering the definition of ‘older’, a differentiation is often made between people under and over 80-85 years of age. This is because the risk of neurodegenerative conditions, such as dementia, is higher for people over 85. That is, the risk of abuse may escalate with increased frailty and/or increasing dependence, and loss of legal capacity – all of which can be heightened issues at the end of life.
Protecting and respecting individual capacity and autonomy – through appropriate assessment paradigms - is particularly important in safeguarding against elder abuse. Capacity is time and decision specific (Purser, 2017). For example, the capacity required to make a will differs from that required for an enduring power of attorney (EPA) and for an advance health directive. The determination of capacity is ultimately a legal decision but there is, worryingly, often little to no reference to the legal requirements for establishing capacity when assessed in a clinical setting. (Purser and Rosenfeld, 2015). Instead, the position often seems to be reference solely to a health professional rather than it being identified as (ultimately) a legal decision ideally resulting from a multidisciplinary assessment process.
Older people can find themselves subject to undue influence– which can lead to financial abuse through, for example, misuse of an EPA (Cockburn, Purser and Cross, 2017). Other pressures such as pharmacological effects, emergencies, and time pressures at the end of life can also heighten the risk of abuse. Consequently, the unique pressures experienced at the end of life can serve to provide and/or exacerbate circumstances in which abuse can occur.
The Australian Law Reform Commission (ALRC) recently reviewed the national legal frameworks making various recommendations with a view to balancing dignity and autonomy with protection of vulnerable older people (ALRC, 2017). The new Banking Code of Practice, commencing on 1 July 2019, also includes provisions to safeguard vulnerable older customers. Further, the recent announcement on 16 September 2018 that a Royal Commission into the aged care sector will be held and media reports detailing abuse in aged care ensure this will remain a key priority. Given the personal and localised effect of elder abuse, community based professionals, service providers, organisations and other stakeholders, particularly lawyers, doctors, social workers, bankers and aged care providers have a significant role to play in combatting elder abuse, especially at the end of life.
Dr Kelly Purser, Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology
Associate Professor Tina Cockburn, Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology
Here are some practical pointers to help health professionals prevent and address elder abuse.