Ethical standards should go beyond end-of-life care
The human rights advocate Jonathan Mann wrote, “Damage to human dignity may have more serious adverse effects on physical, social, and mental well-being than infectious disease.” (Horton, 2004, p. 1084)
Although there is debate about the source of the phrase, “First, do no harm,” it is still relevant and perhaps takes on a deeper meaning when considering Jonathan Mann's statement. How people are viewed by those around them can have a big influence on how they think about themselves, especially when they become ill and rely on others for care.
Try to remember when someone made a dismissive comment to you. Do you remember how you felt? Now consider how a fragile elder receives a dismissive comment from a caregiver. This fragile elder at an earlier time in their life was a vibrant individual, someone's child, spouse or parent. Now, remember when someone smiled at you and encouraged you even though you were having a difficult time. That smile and those encouraging words probably helped you maintain your composure during an undignified moment. The same is true for a fragile elder who is doing all they can for themselves.
Residents in facilities have medical conditions and are vulnerable because they are dependent on others to meet their basic activities of daily living. Reflect for a moment on the loss of independence, identify, and autonomy experienced when entering a skilled nursing facility. How much dignity have you surrendered? What makes your life dignified? How does illness or disability alter that?
As a “baby boomer” I am acutely aware of the physical changes taking place in my body, mind, and soul. My hands do not work as well as they once did and it takes me longer to get out of a car or to get something out of my purse when in a line at the store. Believe me, I hear the remarks and see and feel the looks and stares. I am a confident, psychologically and socially strong individual but I openly admit these comments are very hard to hear and the looks are hard to take.
The ethics about the right and wrong of human behavior is not the least of these points of reference. Every situation in which we find ourselves has ethical considerations. Daniel P O'Mathuna, Ph.D. wrote, “Human dignity captures the notion that humans are uniquely valuable and therefore out to be esteemed highly. If this is accepted, ethics will be helped by identifying whether actions and attitudes affirm or deny human dignity. This makes dignity and ethics very relevant for everyday settings.” (JCN Volume 28, Number 1, pgs.12-18)
Much like ethics, defining dignity may be difficult and defining it within a healthcare setting is not any easier.Healthcare settings should afford anyone providing care and service the opportunity to change an undignified moment into an interaction where human dignity and inherent individual value are promoted or increased.
How dignified is it to be a medically fragile elder to spend the remainder of his or her “golden years” sharing a room with a stranger, separated only by a cloth curtain? Where is the dignity in needing help to go to the bathroom and then waiting for long periods of time for assistance only to end up being incontinent?
Residents in SNFs experience these circumstances and all too often “get used” to it because they have no other choice. As long-term care professionals, we can have a positive impact on each of these situations. We need to seize each opportunity to behave in an ethical and dignified manner ourselves. This behavior should demonstrate and acknowledge the unique value of each individual in our care.
The Centers for Medicare & Medicaid Services places a high degree of importance on dignity as it relates to the care and services provided to an elder in a SNF. Surveyors have been citing psychosocial harm since 2006 but the revisions outlined in Survey and Certification Memorandum 16-15-NH issued on March 25, 2016 are quite comprehensive and show surveyors how they can cite if and when psychosocial harm alone occurs. Previously, a combination of physical and psychosocial harm was generally cited.
With this new emphasis on the scope and severity of psychosocial harm, those of us working in the long-term care environment must ensure behavior while delivering care and services to residents is ethical and does not diminish the resident's dignity.
In diminishing the dignity of any other human being we make a statement about who we are ethically. In delivering person-centered care and embracing a holistic and individualized recognition of each person's individual humanity we also embrace the ethics of dignity. We must and promote the inherent dignity of anyone with whom they interact; resident, colleague, subordinate, or any member of the public.
Kathleen D. Mace, RN, is a senior clinical compliance consultant at Compliagent.