Tip Sheet for August 2001

• Elderly Tend To Hoard Objects In Household
• DEATH: IS IT A CHOICE?The Role of Values in End-Of-Life Decisions
• Reduced Home Health Care Services Cause Ethical Dilemmas for Social Workers

Objects such as newspapers, containers and other papers fill homes of predominantly elderly women to the point where living space cannot be used creating increased functioning and health problems.

In a study in the August issue of Health and Social Worka journal from the National Association of Social Workers (NASW)Gail Steketee, PhD, from the School of Social Work at Boston University, Randy Frost, PhD from the Department of Psychology at Smith College, and Hyo-Jin Kim, MA, a doctoral student at Boston University found that hoarding, a debilitating disorder characterized by the large accumulation of possessions that clutter living areas to the degree that those spaces cannot be used for their intended purpose, occurs in a majority of elderly womens homes who have never been married and live alone.

The study interviewed service providers who work with older people in the Boston area. Many of the elderly hoarders live in urban locations in apartments and averaged an annual income between $10,000 and $40,000, with most falling into the lowest income bracket.

According to the authors, the never-married status was linked to more severe hoarding symptomssignificant clutter in the home, inability to use parts of the living space for intended purposes, and impairment in functioning as a result of the hoardingpossibly reflecting greater attachment to possessions for those who did not have a partner.

The majority of objects collected consisted of old newspapers, containers, and other miscellaneous paper and was predominantly found in the living room, dining room, kitchen, bedroom, and sometimes even the bathroom.

For most of the elderly, the clutter also represented serious physical threats, including a fire hazard, falling, and unsanitary conditions.

Many elderly hoarders had some form of mental disorder, such as affective, personality, psychotic, and anxiety disorders, according to the authors.

Involuntary cleaning of the homes is not a solution to this problem. Hoarding is a multi-faceted problem that involves difficulty with information processing and emotional attachment, erroneous beliefs about possessions, and behavioral avoidance. Effective treatment is likely to require modification of faulty beliefs, assistance with organizing and decision making, and examination of emotional attachment and behaviors that promote hoarding, say the authors.

They propose intervention likely to alleviate the problems caused by the hoarding are ultimate goals to enable the elderly to live effectively and safely in their homes.

DEATH: IS IT A CHOICE?
The Role of Values in End-Of-Life Decisions

Research reveals the values of competence, integrity, loyalty, and legacy as the driving values behind decisions at end-of-life. These values in different life domains; including physical-biological, social-psychological and societal were also connected by the values of dignity, quality of life and quality of death.

The authors, Ronit D. Leichtentritt, PhD, a lecturer at Bob Shapell School of Social Work in Tel Aviv and Kathryn B. Rettig, PhD, a professor in the Department of Family Social Science at the University of Minnesota, St. Paul, intended to encourage individuals to talk about end-of-life decisions as a valuable experience and an opportunity to clarify intentions.

The study, of elderly Israelis, used four hypotheses for end-of lifewithholding treatment, where life is not prolonged by machines; withdrawing treatment, taking life-sustaining machines away; active euthanasia, a physician administering drugs to take a patients life; and physician assisted suicide, a physician supplying the patient with drugs that when taken will result in deathand asked the participants and family members how they felt about each one. The study took place in Israel because of the strong influence of Orthodox Jewish tradition, the recent recognition of patients rights at end-of-life, and the social norms surrounding care for a dying patient.

Leichtentritt and Rettig found that participants made a separation between two forms of non-voluntary end-of-life decisions on the basis of their role in the decision. In other words, different priority of values guided the decisions made by self for another family member, compared with the decision made by another family member made by self.

Participants talked about their biological self when referring to the value of competence. They also included strength, energy, endurance, health, appearance, dignity, and qualities of life and death. When referring to the social-psychological life domain, they highlighted personal values such as integrity, control, rights, wholeness, dignity, and qualities of life and death. In the family life domain, loyalty was the main value underlying end-of-life decisions, regardless of whether the decision was made by members of the family for self, or made by self. When participants took the perspective of citizens in society, they emphasized terminal social values, including legacy, heritage, and community.

Ecological theory acknowledges that an end-of-life decision is an individual, relational, and social-cultural phenomenon. Participants in the decision-making process took into consideration social, community and family contexts, giving attention to past (heritage) and future (legacy) time perspectives, say the authors.

Reduced Home Health Care Services Cause Ethical Dilemmas for Social Workers

In a study published in the August issue of Health and Social Worka journal from the National Association of Social Workers (NASW)home health care workers, including social workers, report ethical conflicts when a patients safety is in question due to decreased mental and physical capacity and, also important, lack of access to services.

The studys authors, Goldie Kadushin, MSW, PhD, an associate professor at the School of Social Welfare at the University of WisconsinMilwaukee, and Marcia Egan, MSW, PhD, an associate professor at the University of Tennessee, Memphis, found that social workers in home health care settings felt that assessing patients mental competence, patient access to services, and patient self-determination were the most frequent ethical conflicts and the most difficult to solve in the home health care setting.

In 1997, as part of the Balanced Budget Act, the Interim Payment System (IPS) was implemented. According the Department of Health and Human Services, the IPS attempts to control the cost and amount of services provided to beneficiaries through the application of payment limits.

In response to this legislation, agencies refused to provide care for the sickest and frailest beneficiaries who require more services or a longer duration of services, while targeting care to relatively health beneficiaries.

This causes an ethical dilemma for the social worker who is pressured by the employer to restrict access to services or prematurely terminate service, despite what might be in the best interest for the patient.

The social worker in this situation is ethically obligated to advocate for patients in their agencies and also on a social level, for health care regulatory reform through the political process.

The National Association of Social Workers (NASW), in Washington, DC, is the largest membership organization of professional social workers with 153,000 members. It promotes, develops and protects the practice of social work and social workers. NASW also seeks to enhance the well being of individuals, families and communities through its work and through its advocacy.