It is the resident without family. It is the patient that can not return home from the hospital because there is no one to help or provide support. It is the resident who has dementia who is unable to speak for themselves that never planned with powers of attorney. It is the developmental disabled young girl whose parents pass away without planning who would make decisions in their stead.
It has been stated by numerous agencies affecting long term care that the “single greatest category of problems we encounter are those that address the care of decisionally incapable patients…those who have no living relatives or friends who can be involved in the decision making process”. These are the most vulnerable of patients. They have no one to speak for them. They have no one to sign consents for them. They have no one to care for them. This type of patient has been termed the “Unbefriended Elderly” by the American Bar Association.
The Abandoned or Unbefriended Elderly can be described as one whom:
- Does not have decisional capacity to give informed consent for treatment.
- Has not executed advance directives and now has no capability to do so.
- Has no legal surrogate
It is estimated that approximately 3-4% of all nursing home censuses are feared to fall into this category. This patient is subject to over treatment, under treatment, or treatment that does not address their wishes or their well being. The facility is also at risk of non payment and/or having their ethics called into question even though they are trying to act in the clients best interest.
Most often the Unbefriended Elderly are people who have been socially isolated much of their lives. The majority of these individuals are encountered at hospitals, nursing homes and frequently have chronic illness.
How does our society handle these clients? How does your health care center handle these clients? Presently, some states have passed legislation for the statutory authorization for healthcare consent when no surrogate is available. Others have enacted laws that authorize trained volunteers to make health care decisions on behalf of the unbefriended individuals. Some states have public guardianship programs. Nursing facilities frequently are put in a quandary over who is to make decisions on behalf of these clients. Ethics committees, physicians are asked to make health care decisions. Social Services are asked to write checks, purchase items, act as representative payee. The Health care facilities are faced with either doing these things for the client, or not getting paid. Is there a conflict of interest?
This involvement is necessary in many cases but does raise some ethical questions. What can be done to assist these clients, ethically, and with ease so that the SNF can do what needs to be done and the rights of the individual are never compromised?
JacksonWhite has made these individuals a priority – to identify and assist these clients to help them have a voice. The Area Agency on Aging has also identified this as a paramount issue. Dawn Savattone, Ombudsman, currently works with these clients to facilitate their health care decisions, ALTCS application or other needed interventions. We applaud their efforts. Our goal is to assist the skilled nursing facility and Ombudsman to find a way to identify and assist these clients to maximize their services, ensure revenue to the skilled nursing center and offer health care direction.
We suggest the following strategies to assist this vulnerable population:
- JacksonWhite has developed an advanced admission screening tool to allow the health care centers to identify the Unbefriended Elderly and how to refer to proper entities to minimize potential problems. This tool also allows for family and friend monitoring, advance directive planning and surrogate investigation.
- JacksonWhite encourages you to make a plan for your center that deals with the specific issues related to this population. Make this plan include what will be done if the client has no family/surrogate and/or client no longer has capacity.
- We encourage and invite you to call JacksonWhite for a review of client status and benefit options. We evaluate whether the client needs a limited conservatorship approved through the court, if they need guardianship, whether or not the client needs the ALTCS program (now or in the future).
Often health care providers try to handle these clients on their own. Administration, Business Office and Social Service usually take the lead. Although this is noble and does bring some resolution we believe that the health care providers are entitled to more support and guidance to reduce any potential conflict of interest and gaps in payment.
We are hopeful that by assisting you in identifying and planning for these individuals we can resolve many of the potential problems before they occur and that we can simultaneously improve the health care and lives of this vulnerable population.
*note – material for this article taken from Incapacitated and Alone: Health Care Decision-Making for the Unbefriended Elderly. By Naomi Karp and Erica Wood. Published by the American Bar Association Commission on Law and Aging.