Tuesday, April 17, 2012

Vulnerable Populations: Terminally Ill Clients and the Elderly

Terminally Ill Clients

Terminally ill clients face extraordinarily challenging issues and decisions that, under the best of circumstances, can be stressful.  They also have to make difficult medical decisions.  Many are in pain or affected in various ways by chemical therapies and pain medications.  Some clients wish to explore the option of  ending their lives, others are angry and afraid (Duba & Magenta, 2008).  Regardless of their personal experience of coping with terminal illness, these individuals are more vulnerable to hardship and trauma than other client populations.  Most of these individuals do not want to deal with death or the idea of assisted suicide in secret, and need someone to talk to (Lowe, 1997), but family members may not be willing to discuss assisted suicide.  The hospice movement continues to play a significant role at this stage of life and offers this population necessary support, although too little is known about how individuals come to grips with this stage of life (Neimeyer, Courier, Coleman, Tomer, & Samuel, 2011).  This further perpetuates their vulnerability.  

Standard A.9.a. of the American Counseling Association's (ACA) (2005) Code of Ethics provides guidelines for end-of-life care for terminally ill clients that counselors should help these clients receive high quality care that fills their needs, supports and encourages their self-determination, and enables their ability for informed decision making in their care.   Standard A.9.b. (ACA, 2005) states that when these clients seek to explore their options for suicide, counselors must be aware of related issues and refer them for the most appropriate help. 
Standard A.9.c. (ACA, 2005) discusses confidentiality as it applies to terminally ill patients who discuss suicide.  The counselor has the option to decide whether to breach confidentiality.  This decision, however, must be made according to the individual's circumstances as well as the law. 

The Elderly

A second vulnerable population is the elderly.  According to Remley and Herlihy (2010), this population continues to grow in this country along with the underrecognized problem of mistreatment of these individuals.  Especially in those people over the age of 75, health issues that compromise their ability to remain autonomous are far more common.  When cognition and normal functioning decline with age, individuals are rendered dependent on family members or an institution for their care.  Not only can this provoke esteem issues, but Remley and Herlihy (2010) claim found estimates that 10 million or more elder adults suffer some form of maltreatment each year.  Even when these elders are being fairly and well-treated, they may still have issues of being dependent on others, fears, or other concerns that are consistent with this age and developmental group.  Although these clients may not be facing end-of-life care issues, they must still be given the right to the autonomy and respect given to all clients.

As long as a client is mentally competent and continues to make self-decisions the counselor must respect their dignity and promote their welfare as stated in Standard A.1.a. (ACA, 2005).  The client continues to have the right to informed consent (Standard A.2.a.) and confidentiality and its limitations (Standard A.2.b.).  Standard A.2.c. charges counselors with being competent and sensitive to the developmental circumstance of the client.  This is significant for elders who may have declined cognitively and physically.  Any information given by the counselor should be understandable and clear.  Certainly, at this stage of life, it remains important for counselors to refrain from imposing their personal values, attitudes, and beliefs onto their clients (Standard A.4.b.).

When any client's legal status changes, it would be important to revisit all the initial considerations of beginning counseling such as informed consent and any confidentiality issues that coincide with the new or changing rights of the individual.  

American Counseling Association (ACA). (2005). 2005 ACA code of ethics [White Paper]. Retrieved from the ACA website: http://www.counseling.org/Files/FD.ashx?guid=ab7c1272-71c4-46cf-848c-f98489937dda

Duba, J. D., & Magenta, M. (2008, October). End-of-life decision making: A preliminary outline for preparing counselors to work with terminally ill individuals. The Family Journal, 16(4), 384-390.

Lowe, A. D. (1997). Facing the final exit. American Bar Association Journal, 83(9), 48-52.

Neimeyer, R. A., Courier, J. M., Coleman, R., Tomer, A., & Samuel, E. (2011). Confronting suffering and death at the end of life: The impact of religiousity, psychosocial factors, and life regret among hospice patients. Death Studies, 35, 777-800. doi: 10.1080/07481187.2011.583200

Herlihy, B., & Corey, G. (2006). ACA Ethical Standards Casebook (Sixth ed.). Alexandria, VA, USA: American Counseling Association.

Remley, T. P., Jr., & Herlihy, B. (2010). Ethical, legal, and professional issues in counseling (3rd ed.). Upper Saddle River, NJ: Merrill/Pearson Education.

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