Unique Features of Adult Day Care: Ethics of Everyday Living Philip Boyle, PhD Vice President. Mission & Ethics Catholic Health East

What I am going to do today? Identify unique moral ecology of adult day care Identify unique moral ecology of adult day care Ethics of caringEthics of caring Caring practices not dilemmasCaring practices not dilemmas Flourishing even in declineFlourishing even in decline Propose a method to identify Propose a method to identify Suggest guideposts Suggest guideposts Identify best practices Identify best practices

The Moral Ecology The clients Impaired sensory, cognitive, & functional Impaired sensory, cognitive, & functional Limit autonomy Limit autonomy Subtle clotting and vulnerabilitySubtle clotting and vulnerability Stigma: Stigma: Attendance =Less than capacitatedAttendance =Less than capacitated Adult day care = baby sittingAdult day care = baby sitting

The Moral Ecology The staff—different professional training Professional boundaries unclear Professional boundaries unclear Becoming intimate with the clientBecoming intimate with the client Self disclosure, identifying with client, accepting or giving gifts Self disclosure, identifying with client, accepting or giving gifts Coercion— behavioral limits Coercion— behavioral limits Provider no longer the “expert”--power Provider no longer the “expert”--power

The Moral Ecology The setting Community care setting Community care setting Less health care, more social servicesLess health care, more social services Not thought as social obligations Not thought as social obligations Institutional configurations varyInstitutional configurations vary Quasi-intitutionalQuasi-intitutional Clients voluntarily purchasing serviceClients voluntarily purchasing service Relief for informal caregiversRelief for informal caregivers

Focus of concern Caring Caring Dignity Dignity Flourishing Flourishing

Ethics of Care Pull of responsibility, not demand of obligation Pull of responsibility, not demand of obligation Attention to particulars, not rules & principles Attention to particulars, not rules & principles Focus on who gives care/power differential Focus on who gives care/power differential Alleviate pain of aloneness, of vulnerability, of fear, of abandonment, of illness, of dying Alleviate pain of aloneness, of vulnerability, of fear, of abandonment, of illness, of dying

Agitated Mary Attends 1 yr Attends 1 yr Dementia 4 yrs Dementia 4 yrs Generally cooperative Generally cooperative 1 day last week became upset 1 day last week became upset Upset escalated Upset escalated Clients notice Clients notice Called family for early pick up Called family for early pick up

Adult day care What is the ethical problem? What is the ethical problem? Would it be framed differently if told from the perspectives of each party involved?Would it be framed differently if told from the perspectives of each party involved?

Adult day care What values are important to preserve? What values are important to preserve?

Adult day care What facts are needed before discharging Mary? What facts are needed before discharging Mary?

Adult day care What actions might respect each person involved in caring for Mary? What actions might respect each person involved in caring for Mary?

Adult day care What kind of care plan ought to be developed? What kind of care plan ought to be developed? Think of aims that go beyond the immediate need of her confusionThink of aims that go beyond the immediate need of her confusion

Angela Stroke, blind unable to carry out directions Stroke, blind unable to carry out directions Capacitated Capacitated Disagrees about everything Disagrees about everything Escort often has problem returning her home Escort often has problem returning her home Staff has given up going the extra mile Staff has given up going the extra mile

Kate, Ralph, & Manager Kate has dementia Kate has dementia Increasing loud activity Increasing loud activity Talking out loud Talking out loud Pulling at clothing and in their faces Pulling at clothing and in their faces Manger worried about clients could strike out at Kate Manger worried about clients could strike out at Kate Husband told they would have to look to alternatives & he responds in anger Husband told they would have to look to alternatives & he responds in anger

Meeting Miss Jones 74 yr old progressive Alzheimer 74 yr old progressive Alzheimer Sister brings Jones to center because she feels confined at home Sister brings Jones to center because she feels confined at home Jones become agitated when sister leaves Jones become agitated when sister leaves What are the most important behaviors to welcome Jones? What are the most important behaviors to welcome Jones? How can you build trust? How can you build trust?

Guidelines for Caring Practices Greet with surname Greet with surname Introduce your self with a story Introduce your self with a story Create a sense of equality Create a sense of equality Put yourself in their position Put yourself in their position Honor privacy Honor privacy Create opportunity to find out what actions they value Create opportunity to find out what actions they value Understand client’s habits Understand client’s habits Talk normally Talk normally

Guidelines for Caring Practices Discover that they want you to let others know Discover that they want you to let others know Promote adult choices Promote adult choices Learn about past & hopes Learn about past & hopes Be aware of invasive elements of care Be aware of invasive elements of care What supports client’s self-worth What supports client’s self-worth What is you way of understanding a problem? What is you way of understanding a problem?

What amount of harm should warrant action? Serious harm Serious harm Likely to happen Likely to happen Alternatives have been exhausted Alternatives have been exhausted Intervention will stop the harm Intervention will stop the harm

Conclusions Ethics of everyday living Ethics of everyday living Attention to particularities Attention to particularities Focus: caring, listening, respecting… Focus: caring, listening, respecting… Need separate mechanisms Need separate mechanisms