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The Balance of Honoring Autonomy and Ensuring Safety

How to navigate a fine line in elder care


Elder Walking Alone
Elder Care and Independence

For over 21 years this has been the foundation of what Elder Care Access's team is constantly evaluating. In today's "sue happy" society, our decisions are driven more by money, than by common sense.  Gone are the "good old days'' when we allowed our elders to be self-reliant, independent, and have a say in the bottom line, even if they are making scary decisions for themselves. Years ago, I used to work with protective services, which meant that ECA got referrals on clients that were found to be "unsafe" in their environment, or that someone else was creating an unsafe environment. In the former, it was my role to determine what is needed in order to create safety. But in doing that, there would be a multitude of conversations with the elder about "what do YOU think of your current situation? People say you are unsafe- what are YOUR thoughts on that?" Many times, I would hear "They don't really know how I manage being alone- they have not asked me the questions of how I manage the things they say are unsafe- I have lived this long without help, I don't need it now." 


So how do we, as a society, as family, and as Geriatric professionals gauge safety? On one hand you can look at the laws and regulations that govern our community. There are laws against elder neglect, abuse, exploitation, and there are regulations and statutes about what to do in those circumstances. But we focus on the average 90 year old that has led a successful, independent, and fruitful life. She prides herself on creating her own way of "being" in this world. At 45, when she decided to quit work, drive across the country with no plan, very little resources and little to no contact with family and friends, that meant she was eccentric, strong-willed, adventurous, and following her heart. 45 years later when this same person, at 90, wants to keep the scatter rugs collected from her travels around the world and refuses to use the walker, Physical Therapy is suggesting that she's "defiant and unreasonable."  What changed? At 45 she had very little regard for rules and prided herself on being independent. Just because she is 90, does that have to change? 


All great questions and ones that healthcare professionals are challenged with every day. Including myself. It is SO EASY to get caught up in the "should's'' of the world. "You should remove those scatter rugs to avoid a catastrophic fall" or "you should use the walker to prevent a hip fracture" or "you have lost weight, let me order Home Delivered Meals''. All great intentions but are we taking the TIME to learn what makes each person "tick"? What drives each individual's decisions, or are we putting them "in a box" that societal norms set? The medical system dictates one thing, the insurance system dictates something very different- oftentimes. The "Elder Care System" has their own set of recommendations and likewise so does the housing system, the home care systems, and the assisted living systems. The VNA's and hospitals are all stringently regulated, and it does seem as if our elders are placed into a category. 


This quick blog is not meant to solve this issue, but to open up a dialogue and create an awareness that "best laid plans" come from well-intentioned, thoughtful, experienced professionals, and loved ones every day. Most do not set out to create barriers to independence, but really want their client/loved one safe. I have worked with senior citizens all of my adult career, and still have to remind myself that these people have lived very long, productive lives. They have raised families, held jobs, taken care of their homes, traveled the world in some cases. They have taken risks for upwards of 60 years! I am suggesting that as professionals, we should slow down our desire to "jump in and fix it” to keep them safe and maybe listen more, ask more questions, involve them in the massive changes that come along when one is experiencing memory loss or physical frailty. In the same way our judicial system says we are "innocent until proven guilty"...I propose we consider our elders "safe until proven unsafe." 


All my best


Sheryl Fappiano LSW, CMC, Owner


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