Volume 9, Number 2, July 1998

A Case Study: Abuse in Care

Randall W. Sargent, MD, CCFP
Medical Director, Bethany Care Society
Calgary, Alberta

Not all residents of long-term care facilities are elderly. Frequently, the reason for admission of young resident is related to trauma or to a debilitating disease process. That was the case for this resident. He was a young male who had once been an example of fitness and male prowess; lots of girlfriends, fast crowd, and very proud. Increasingly, he lost even the capability to care for himself and had to finally concede to admission to a long-term care facility. This lead to anger and numerous interactions with staff from which arose complaints of physical threat and injury. Most workers were afraid of him, and a plan for tandem care was finally arranged once a facility was found that was willing to have him as a resident.

Staff found that despite his anger, certain individuals had an easier time carrying out the patient's activities of daily living, such as washing, positioning, and feeding. He was by that date virtually unable to help himself and his language skills were frustratingly few. One of the staff members who was able to work with this young man was a female worker who was between relationships and expressed to her co-workers that the care of this patient was appealing in more than the usual way. Her work was, however, temporary and she soon moved on to other employment. She did, however, return to visit this young resident and was soon coming often.

One of the things she noted early in the relationship was the pleasure of touch that this resident enjoyed. This was in contradiction to most staff members experience since pain was part of the realm of symptoms this resident was dealing with and touch was usually painful. Nevertheless, the touch of this woman was not rejected and in her mind it was encouraged. The exact nature of conversations was private since staff members felt somewhat confused as to the role this former staff member was now assuming. The visits became regular and frequent, often lasting only for an hour or less at various times during the day, such as lunch or evening time. Since it did not directly interfere with the usual staff contact with the patient, a respectful space was allowed. This created an air of mystery around the relationship that became a focus of interest on the unit where the resident lived.

Soon the visits were veiled in secrecy with the curtain drawn about the bed and interesting sounds emanating from the area, and although no specific facts were gathered, it was assumed that the visits had assumed a conjugal nature. From their remote position, staff members involved in the resident's care constructed an interpretation of this visitor's activity of physically stimulating the resident and the pleasure both appeared to derive. There was no question this resident was likely to enjoy these activities as evidenced by his past social activities, the bragging he had done in the past, and the celibate lifestyle of recent years.

So what happened? Is this abuse? The problems arising for staff members revolved around the responses of themselves and, increasingly, the notice of other residents. Eventually, a more senior staff member from the unit approached this young woman and the visits stopped almost immediately. The resident never discussed the relationship with anyone employed in the facility, but the gossip train was moving and the stories became legendary.

Case Study Commentary

Al-Noor Nathoo, Southern Alberta Coordinator
Provincial Health Ethics Network

Discussion

At the heart of this case lies the question of potential abuse through a violation of the healthy boundaries that normally exist between provider and beneficiary of care.

Professional boundaries have been defined as "separating therapeutic behaviour... from any behaviour which, well intentioned or not, could lessen the benefit of care to patients... Boundary violations occur when there is confusion of the professional's needs with the client's needs. A boundary violation is typically characterized by a reversal of roles, secrecy, the creation of a double bind for the client, and the indulgence of personal privilege by the professional.l" Abuse involving a boundary violation occurs when there has been a betrayal of the fiduciary relationship, or agreement of trust, that exists between care providers and recipients of that care who become vulnerable because of their need for health care.

While the inappropriateness of sexual relationships between care providers and their clients over the course of the therapeutic relationship has been well established, the question of whether it is ever ethically acceptable for caregivers to enter into intimate relations with former clients (who are competent) is a more controversial one. The answer to this question clearly depends on the nature and history of the relationship itself. At the heart of determining whether a relationship is healthy or not lies a question of respect; of whether an existing association between two individuals is grounded in the affirmation of the dignity of each person, in true consent or choice, and in proper representation and disclosure of relevant information. Yet the kind of relationship that existed between the care provider and the resident that likely lead to intimacies here is difficult to determine at best, from an outsider's perspective.

Filling in the Details

If 'good' ethics, like law, must be based on accurate 'facts', the first step in attempting to determine whether this might be a situation of abuse would be to seek more information. From what sources are the facts of the case, as presented above, gleaned, and how reliable are they? What, if any, support was provided to the caregiver by members of the institution assisting her to identify and work through the issue herself? How did the resident's perceived aggressive behaviour (which may, if extreme, have been another form of abuse) towards other caregivers affect his relationship with this particular care worker?

Furthermore, to what level of closeness or intimacy did the relationship progress before the care provider left the employ of the care centre? Who initiated the relationship (keeping in mind that a resident-initiated rather than care provider-initiated relationship may do nothing to mitigate the seriousness of the abuse, if it exists)? If the resident, did there appear to be any element of coercion, manipulation or use of guilt over time to assuage the care provider to see things in a way that might result in her making decisions she would later regret? If the care provider, did the resident feel in any way obliged to respond positively to the care provider's advances lest his care suffer? A better understanding of the circumstances surrounding the relationship is required in order to consider whether several of the defining characteristics of abuse may or may not be present.

Once this information is available, one can go on to examine whether the key principles of ethical provider-client relationship have been respected. Has the caregiver respected the primary duty of all providers to contribute to the well-being of their clients (beneficence), not of their own? Perhaps more importantly, what of the oft-cited injunction that caregivers should, above all, 'do no harm' (non-maleficence)? How is harm to be understood in this situation? While the potential negative consequences of such a relationship would have to be considered, one would also have to take into account any benefits the relationship may have offered. If the post-therapeutic relationship can be deemed to be a healthy and freely-chosen one, it may be that attempting, discreetly or explicitly, to put an end to it might be harmful. Thus, discouraging a relationship that could potentially contribute a great deal to promoting feelings of self-worth, autonomy and to the enjoyment of life, might turn out to be inappropriate or unethical.

Systemic Concerns

The issue of promoting individual autonomy also gives rise to larger questions about justice and the role of the institution in providing an environment for healthy relationships to flourish. The confines of a long-term facility provide well-known obstacles to cultivating healthy human relations, intimate or otherwise, and pose challenges to both administrators and residents in seeking forums for privacy, respect and accommodation of the need for personal space.

If care centres strive to build an atmosphere which its residents feel reasonably approximates and which they may come to call 'home', this raises institutional policy concerns regarding what resident activities could justifiably be curtailed for the sake of the comfort of other residents, visitors and staff or the effective functioning of the institution. The particular situation of a (former) caregiver-resident (as opposed to resident-resident) relationship provides an additional twist to the issue, but the underlying systemic concern of how continuing care centres can promote healthy relationships remains central. It is also a crucial one, in light of accumulating evidence which suggests that human contact and caring relationships contribute significantly to better health and survival than has previously been recognized or acknowledged.

Healthcare institutions in the West exist within societies that have largely adopted a framework of liberalism; individuals are allowed to engage in whatever activities and subscribe to whatever beliefs they choose. The only exception to this general principle is where such activities or expression of beliefs would infringe upon the potential exercise of those same rights by other individuals living in the same society. That is, my stamp collecting may be a hobby which gives me great pleasure, and there is little reason for a nation to outlaw the sport unless it was somehow dangerous to the health and welfare of other citizens of that state, or in extreme cases of my own - a scenario that would be difficult to envision in the case of such a non-violent hobby. If such are the freedoms we normally allow our citizens, long term care centres may need to provide justification for not extending those rights to their own residents.

In other words, we may wish to ask the question - what harms resulting from the relationship between this care provider and resident, either to themselves or to others, would be sufficiently compelling to justify trumping, through some sort of organizational intervention, the presumed right of residents (citizens) to engage in activities that add to their enjoyment of life and to their happiness? In the absence of clear indication that a former caregiver-resident relationship is a potentially harmful one in more than the usual way (for who hasn't been harmed by unhealthy relationships?), the institution may in fact be ethically obliged to promote, rather than discourage, intimacy.

Support for Dealing with Conflict

Aside from addressing larger systemic issues of promoting autonomy and healthy relations, an additional consideration when examining potential cases of abuse is the means available to address these concerns as they arise - before they turn into crises or are forced into the legal sphere. Issues of potential boundary violations, particularly those involving romantic or sexual liaisons, can too easily be veiled in a secrecy that, while respecting the confidentiality and delicacy of such matters, fails to acknowledge that caregivers too are human beings whose feelings of attraction or attachment to particular residents or patients are part of normal human experience.

Such feelings, with the support of colleagues and supervisors, can be recognized and dealt with in a way that respects the natural inclination of caregivers to form strong bonds with clients with whom they work daily and intimately, but that never allows such feelings to translate into actions that could violate the primacy of caregivers' duties to their clients to avoid harm and promote well-being. The important distinction to be made then is in acknowledging that while having such feelings may be normal, acting on them may be inappropriate.

Conclusions

As is often the situation, it would be premature to begin a proper discussion and analysis of this case without further information and without input from the resident and caregiver in question. Only then would a clearer picture of the nature of the former provider-patient relationship emerge, and thus of whether that interaction may constitute abuse.

It is often said that the heart of ethics lies in relationship, not in rules or principles which theoretically define the boundaries of right and wrong. That this may indeed be the case is particularly well demonstrated by the above example, where the principles of autonomy, justice, beneficence, non-maleficence and others help in highlighting areas of concern but where a final determination of the true nature of the relationship, the sincerity and intentions of the key players and the level of mutuality and freedom of choice is difficult if not impossible to gauge for anyone confined to doing ethics from a distance. That care providers who are obligated to report suspected cases of abuse may be required to practice 'distance ethics' in considering whether to report such situations is an unfortunate drawback, although perhaps an unavoidable one, to any such legislation. It demonstrates well the continual tension between the field of ethics, which encourages action that is compassionate and just - and the law, which enforces it.

Reference(s)

1. Professional Boundaries for Registered Nurses: Guidelines for the Nurse-Client Relationship, Alberta Association of Registered Nurses, April 1998, p.1 and p. 5.