e-Ethics AUGUST 2002
Granny Bryce's Condition: Elder Abuse?
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Connie Smith, Gertrude Bryce's
eldest grandchild, brought her into
the hospital for her pre-op workup.
Gertrude, known widely as "Granny"
Bryce, lived with Connie and their
extended, intergenerational family.
While all were somewhat hot tempered,
family members seemed to
like and respect one another. The
staff at the hospital had witnessed
more than one shouting match
among them, especially between
Connie and Granny; but always
peace was quickly restored.
Granny's doctor had recommended
a pacemaker some months
ago and finally the family had convinced
her to accept it. Although
she could be a pistol—and was
hardly their most compliant
patient—Mrs. Bryce was a hospital
staff favorite. They always took a
little extra time with Granny. At 83,
she was not a large woman, but she
certainly was not frail. Indeed, she
was quite robust and energetic for
an elderly woman. During her pre-op
workup, however, the nurse
noticed that she had lost ten pounds
since her last visit just a few weeks
earlier. The nurse later noticed that
Granny had bruises on her shoulders,
arm, and chest. When asked
about her weight and the bruises,
Granny made light of both: it was
summer and she wasn't very
hungry; she couldn't explain the
bruises, maybe she got them playing
with her great-grandson or
bumping into furniture in their
crowded apartment.
The nurse suspected elder abuse
and reported her concerns to the
physician, who discreetly questioned
Granny about her condition but
learned nothing further. Granny
refused to elaborate. At a loss to
explain her condition, the doctor
became suspicious.
Discussion
Elder abuse is a very serious
matter. According to the late Rosalie
Wolf (2000), a widely respected
authority, elder abuse "is an all
inclusive term representing all types
of mistreatment or abusive behavior
toward older adults . . . Whether a
behavior is labeled abusive, neglectful,
or exploitative may depend on
its frequency, duration, intensity,
severity, consequences, and cultural
context" (p. 7). Elder abuse may
have obvious signs, such as severe
bruising or evidence of malnutrition,
but it also includes the more amorphous
self-neglect, which may be
the most common form of abuse;
neglect by responsible caregivers; or
financial exploitation. All suspected
instances in the state of Illinois are
reportable to public authorities. A
call to the Senior Help Line at 1-800-
252-8966 will provide details about
the local agency designated to
investigate cases of abuse. These
agencies strive to end the abuse
without destroying the relationships
that the older person relies on to
meet the demands of daily living.
An elderly person's healthcare
providers are usually the first line of
defense in identifying suspected
abuse and making the referral. So it
is critical that physicians, nurses,
social workers, and other personnel
know about their local agency. In
addition to the case management
services offered by the investigating
agency, the physician should consider
referrals to nursing, psychiatry, or
social services, perhaps especially in
cases of apparent self-neglect (Dyer
and Goins 2000).
State-mandated reporting
requirements often put healthcare
workers in a bind. In Granny's case,
given the volatile nature of the
family, caregivers should seek to
learn how the bruises occurred and
why she has lost so much weight.
Although the law does not require
reporters to investigate, it is wise to
seek to rule out alternative causes of
suspect signs. It is essential to prevent
abuse from occurring or recurring;
it is also important to avoid
unnecessary disruption of family life
since alternative living situations are
often not readily available to the
elder. Reasonable grounds rather
than reckless surmise should be the
guiding principle.
Although an older person will,
like Granny, usually do almost anything
in her power to protect her
family even if they are abusing her,
healthcare providers have a legal—
and moral—duty to follow up on
their suspicions. Again, the provider
is not obliged to conduct an exhaustive
investigation; if there is reasonable
suspicion of abuse, it must be
reported. The person filing the report
need not inform anyone else. After the
report has been made, the agency must
maintain confidentiality. The reporter is
not informed about the progress or
final outcome of the case.
Most states, including Illinois, use
an adult protective services model that
has distinctive emphases: client self-determination;
the right to the least
restrictive environment possible; maintenance
of the family unit, whenever
possible; a preference for community-based
services over institutions; non-ascription
of blame; and a conviction
that inadequate services are worse
than none (Otto 2000). The central aim
of investigating agencies is to prevent
unnecessary suffering. They recognize
that the relationship between the elder
and her caregivers is often key to her
well-being—not only essential to her
continued ability to remain in a less
restrictive environment, but also at the
heart of her life and morality. The
agency will try to determine, to the
extent possible, the reasons for the
abuse and will emphasize the services
that can be made available to the caregiver
should the cause be extreme
stress. The agency can work with the
client for up to 15 months in an effort
to resolve the abusive situation.
Unfortunately, preserving the current
living situation while completely
eradicating abuse is not always possible.
The elderly victim simply remains
at risk. These situations, which create
the most intractable problems, call for
ongoing negotiation, close monitoring,
and as much intervention as time and
money will permit. The issue of elder
abuse demands urgent attention and
creative solutions as our society rapidly
ages. Those charged with identifying
elder abuse and responding to it in
healthcare settings must be not only
vigilant but proactive.
1. Dyer, Carmel Bitondo, and Angela M. Goins.
2000. "The Role of the Interdisciplinary Geriatric
Self-Assessment in Addressing Self-Neglect of
the Elderly." Generations 24, no. 2 (Summer):
23-27.
2. Otto, Joanne M. 2000. "The Role of Adult
Protective Services in Addressing Abuse."
Generations 24, no. 2 (Summer): 33-38.
3. Wolf, Rosalie S. 2000. "The Nature and Scope
of Elder Abuse." Generations 24, no. 2
(Summer): 6-12.
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