1. Elder Abuse at End of Life
The Hidden Problem

2. Types of Abuse Abuse: physical, emotional, and sexual
Neglect: self and other
Exploitation: financial and sexual
Abandonment

3. Extent of the Problem
No one knows for certain how big the problem is because relatively few cases are identified.
It is estimated that 2 million older adults are mistreated each year in the U.S.
5 of 6 cases are NOT reported
Hospice and palliative care patients have multiple risk factors
Dependent on others for care
Cognitive impairment
Caregiver stress

4. Who is at Risk
Elder abuse can occur anywhere – in the home, nursing home, or other institutions
It can affect the elderly across all socio-economic groups, cultures, and races
Women and “older” elders are more likely to be victims
Dementia is a significant risk factor
Mental health and substance abuse issues are risk factors
Isolation can also be a risk factor

5. Victim and Abuser Behaviors
A Victim May…
An Abuser May…
Have injuries that do not match the explanation of how they occurred and have repeated “accidental injuries”
Appear to be isolated
Say or hint feeling afraid, coded messages about what is occurring
Minimize or deny the victim’s injuries, attempt to convince others that the victim is incompetent or crazy, blame the victim for being clumsy or difficult
Physically assault or threaten violence, prevent or forbid victim contact with others
Act overly attentive towards the victim, especially in the presence of others

6. Victim and Abuser Behaviors, contd
A Victim May…
An Abuser May…
Consider or attempt suicide
Have a history of substance abuse
Be “difficult” or hard to get along with
Consider or attempt suicide
Have a history of substance abuse
Refuse to allow an interview with the victim without being present, speak on behalf of the victim

7. Victim and Abuser Behaviors, contd
A Victim May…
An Abuser May…
Be emotionally and/or financially dependent on the abuser
Show signs of depression, stress, or trauma
Have vague, chronic, non-specific complaints
Be emotionally and/or financially dependent on the victim
Turn family members against the victim, talk about the victim as though they are not there or not a person
Say the victim is incompetent, unhealthy or crazy

8. Signs and Symptoms
Why is this a bit tricky at end of life? Physical, behavioral, and emotional changes that happen at end of life may also be signs of possible abuse, neglect, or exploitation.

9. Warning Signs
Physical: slap marks, unexplained bruises, pressure marks, burns, blisters
Neglect: pressure ulcers, filth, lack of medical care, malnutrition or dehydration
Emotional: withdrawal from normal activities, unexplained changes in alertness or other unusual behavioral changes
Sexual: bruises around the breasts or genital area and unexplained STDs
Exploitation: sudden change in finances and accounts, altered wills and trusts, unusual band withdrawals, checks written as “loans” or “gifts”, loss of property

10. Be Aware of Additional Risk Factors
Hospice Patient
Caregiver
Increasing frailty
Cognitive impairment
Increased assist with ADLs
Display of abusive behavior
Unstable/poor social supports
Conflicted relationships
Perception of stress
Dependency on patient
Poor relationship prior to illness
Substance abuse
Mental illness
Burnout/frustrations
Lack of skills
Depletion of resources

11. What are we to do? Educate ourselves and our team
Increase communication among the hospice team to include each member’s observations and awareness when you suspect a situation.
Our policy requires that our staff immediately report any suspected case of abuse, neglect, or exploitation to his/her immediate clinical supervisor or to the Clinical Counseling Officer.

12. Reporting is Mandatory
Remember that you don’t need proof of abuse, neglect, or exploitation to make a report – reasonable suspicion is all that is required
Involving adult protective services does not mean your team failed
Don’t assume that someone has already reported a suspicious situation. Most cases go unreported.
Any individual who is legally mandated to report suspected abuse, neglect or exploitation and who intentionally fails to report such is guilty of a misdemeanor and liable for damages cause by failure. KRS Chapter 209

13. Why we fail to report… Lack of awareness of problem
Insufficient understanding
Loyalty to patient/family
Legal and practical consequences
Feeling of failure
Assumptions about adult protective service response
Denial of mistreatment
Lack of recognition of warning signs
Potential effect on rapport with patient and family

14. Key Points Get management support
Include team members and supervisors from the very beginning of seeing any of the warning signs
Keep focus on enhancing quality patient care