Abuse in the home: When your patient is in danger
Hospice workers put in awkward position
Their 50th anniversary was coming up, and the husband had casually told a hospice home health care worker that he intended to have sex with his wife "if it’s the last thing I do."
Never mind that she was bedbound, had a catheter, and was unable to speak because she had had a stroke. She was his wife, and he had a right.
Although the hospice aide had heard his comments, she paid little attention to them until her next visit, when she noticed the woman was more withdrawn than usual. During bathing, she noticed bruising and vaginal bleeding and called her supervisor.
The supervisor sent a nurse to calm the aide and question the patient until she could piece together what had happened. The husband indeed had "celebrated" their 50th anniversary, just as he’d promised. The hospice called it rape and notified police.
Home health care workers, because of their access to the most intimate aspects of their clients lives, are sometimes forced into the precarious position of being both health care giver and police officer. "We’re seeing things in the home that we didn’t need to worry about before. Are they happening more, or are we becoming better educated?" says Bonnie Kosman, MSN, RN, CS, CDE, director of patient care at Lehigh Valley Hospice in Allentown, PA.
But the mission of hospice can come into conflict with the situation.
"We have a strong bias toward people staying at home, but sometimes it’s not very safe," says Constance Holden, RN, MSN, executive director of Hospice of Boulder County, CO. "If they’ve been abused the last 50 years, in the last two weeks of life, are we talking about taking them to a nursing home?"
While sexual abuse of elders is rare less than 1% of reported cases in a 1990 to 1994 study of domestic elder abuse other types are not. The National Center on Elder Abuse (NCEA) in Washington, DC, which collects data on reports of elder abuse, notes that physical abuse accounted for 15.7% of total abuse cases in two national surveys. Neglect accounted for 58.5% of the cases. NCEA also notes that as few as one in 14 domestic elder abuse incidents come to the attention of authorities.
Most states mandate that hospices report suspected abuse. To win approval from the Joint Commission on Accreditation of Health Care Organizations in Oakbrook Terrace, IL, a hospice is required to have a written plan for identifying and reporting alleged or suspected abuse and identify agencies that can assess these cases, such as Adult Protective Services, the Area Agency on Aging, or the local social services department.
"Organizations may want to consider elder and child abuse laws in their states when they develop their criteria," says Debra Payne, RN, BSN, CRRN, associate director of the Joint Commission’s Department of Standards Interpretation.
Experience, instinct, and attentiveness play a large part in recognizing abuse. So does training. Lehigh Valley Hospice, for example, has its social workers go over the hospice’s reporting plan line by line when they give inservice training.
At Hospice Care Network in Westbury, NY, the matter is reported to a supervisor, who usually pulls in the social workers because they are familiar with the formal agencies, says Jeannette Coane, RN, MA, director of quality improvement and staff education. "A team conference will be called with the multidisciplinary team, and we might call in the family if have reason to. We may call Adult Protective Services, or if the neglect or abuse is severe, call the police," she said.
States that require agencies to report alleged or suspected abuse or neglect usually protect hospices from potential liability. Under the Revised Code of Washington, for example, a person reporting or testifying in good faith about abuse is immune from liability resulting from the report or testimony.
"If a hospice is a mandated reporting agency, it’s not up to those people to determine if it is abuse or neglect," says Melanie Johnson, BSW, adult protective service program manger for the Aging and Adult Services Section, Home and Community Programs for the state of Washington.
"It’s up to them to report it," she says. "The determination is made by the Adult Protective Services social worker."
[Editor’s note: The National Center on Elder Abuse offers training videos for purchase or loan, as well as materials that list signs and symptoms of abuse. It can be reached on the Internet at http://interinc. com/NCEA or by telephone at (202) 682-2470.]
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