Like all psychology practice, professional geropsychology practice is guided by the American Psychological Association Ethical Principles of Psychologists and Code of Conduct (see Ethical principles of psychologists and code of conduct (apa.org). Ethical practice with older adults, families, and related care systems entails additional and complementary knowledge and skills, due to specific clinical issues and settings of care for many older adults. These issues include changes in decision making capacity and/or vulnerability to abuse or exploitation for some older adults, care frequently delivered in interdisciplinary, family, and other systemic contexts, and increased prevalence of end-of-life and surrogate decision making in late life.
The Pikes Peak Geropsychology Knowledge and Skill Assessment Tool (Karel, Emery, Molinari et al., 2010; Karel et al., 2012) breaks the foundational geropsychology competency regarding ethical and legal standards into four specific abilities:
1. Tension between promoting autonomy and protecting safety of at-risk older adults. Most healthcare professionals value both the self-determination and safety of their patients but sometimes these goals conflict; team members may disagree about the primary emphasis, based on personal and professional values (Mezey et al., 2002; Qualls & Czirr, 1988). People with intact decision-making capacity have the right to make risky, eccentric, or otherwise unpopular decisions, as long as they do not put others at risk. However, people who have difficulty understanding and appreciating the risks and benefits inherent in a situation need assistance negotiating that difficult balance between doing what one wants and doing what may optimize one’s safety and well-being. This tension arises regarding medical, financial, residential, driving, relational/sexual, and other types of life decisions. Geropsychologists are aware of this tension; are able to reflect on their own values and those of patients, families, team members; and help to negotiate care decisions in this context.
2. Decision making capacity and strategies for optimizing older adults’ participation in decision-making. Decision making capacity falls along a continuum, with a range of diminished capacities between full capacity and incapacity. Capacity is also domain specific, context dependent, and may change over time. Geropsychologists understand concepts of decisional and functional capacity and models for evaluating capacity (American Bar Association Commission on Law and Aging and American Psychological Association, 2008; Moye, 2020). Geropsychologists optimize an older adult’s decision-making participation by addressing sensory deficits, reducing distractions, using visual and memory aides, asking questions simply and clearly, and demonstrating respect for the older adult’s input, as well as respect cultural and personality differences in the extent to which older adults wish to take an active role in decision making.
3. Surrogate decision making. Many fully capable older adults prefer and benefit from making decisions collaboratively, with family members or friends serving as social supports and/or advocates. Surrogate decision making refers to one person being responsible for making decisions on behalf of another, when that person is no longer capable to make informed decisions for herself. Surrogate decision makers are most often family members or friends but may also be court appointed legal guardians when next of kin are not available. Geropsychologists are aware of the challenges surrogates face in making decisions for others (Vig et al., 2007; Wilkins, 2021) and are able to support a consensus-based approach which considers what is known about an older adult’s past and present values and priorities, along with the burdens and benefits of different treatment or other decisional options.
4. Clinical and legal tools to protect self-determination and safety of older adults. Geropsychologists are aware of clinical and legal resources available to help older adults plan for potential future incapacity, as well as to help protect vulnerable older adults. Resources to aid advance care planning include: proxy and instructional advance directives (e.g., National Hospice and Palliative Care Organization, 2023, CaringInfo: Resources for Serious Illness & End-of-Life Care; American Bar Association Commission on Law and Aging, 2023, Health Care Decision Making (americanbar.org)). A number of legal tools are available to protect older adults’ interests in the event of incapacity (or after death), which can be arranged by older adults themselves ahead of time (e.g., financial power of attorney, last will and testament) or by the court if needed (e.g., guardian, conservator, see American Bar Association Commission on Law and Aging, 2023, Guardianship and Conservatorship (americanbar.org)). Likewise, geropsychologists are aware of laws regarding reporting of elder abuse and neglect (see NCEA – Home (acl.gov)) and of community resources to protect vulnerable elders (e.g., see Home Page | ACL Administration for Community Living).
Geropsychologists understand the ethical implications of geropsychological assessment, intervention, consultation, and research activities (e.g., Bush, Allen, & Molinari, 2017). Across these functional domains of practice, important ethical issues to consider include: informed consent and assent, confidentiality (e.g., communication with teams and/or family members), privacy, reliability and validity of tests, applicability of assessment and intervention strategies among older adults diverse with respect to cultural and educational background, multiple roles, conflicts of interest (e.g., serving the older adult and the health care facility), accurate coding and billing for services.
Geropsychologists are able to identify and utilize a model or framework to help guide ethical decision making in practice. Per Karel (2010), here is one framework that draws on core features of several models:
1. Clarify the ethical issue. What is the dilemma?
2. Clarify who are the relevant stakeholders and each of their values, goals, and interests.
3. Clarify decision making authority. Who has the right to make the decision in a particular situation?
4. Consider all ethically justifiable options, and their pros and cons for each stakeholder.
5. Implement plan, evaluate, and reevaluate.
And, per Bush, Allen, & Molinari (2017), the CORE OPT model for ethical decision making in geropsychology has these steps:
• Clarify the ethical issue
• Obligations owed to stakeholders
• Resources (ethical and legal)
• Examine personal beliefs and values
• Options, solutions, and consequences
• Put plan into practice
• Take stock, evaluate outcome, and revise as needed
Written by Michele J. Karel, PhD, ABPP, Board Certified in Geropsychology
Adapted from: Karel, M.J. (2011). Ethics. In V. Molinari (Ed.) Specialty competencies in geropsychology (pp. 115-142). New York: Oxford University Press.
Also, for a key text, please see: Bush, S.S., Allen, R.A., and Molinari, V. A. (2017). Ethical practice in geropsychology. Washington, DC: American Psychological Association.
Wilkins J. M. (2021). Reconsidering gold standards for surrogate decision making for people with dementia. The Psychiatric Clinics of North America, 44(4), 641–647. https://doi.org/10.1016/j.psc.2021.08.002
Moye, J. (Ed.) (2020) Assessing capacities of older adults: A casebook to guide difficult decisions. Washington, DC: American Psychological Association.
Karel, M.J. (2011). Ethics. In V. Molinari (Ed.) Specialty competencies in geropsychology (pp. 115-142). New York: Oxford University Press.
Bush, S.S., Allen, R.A., and Molinari, V. A. (2017). Ethical practice in geropsychology. Washington, DC: American Psychological Association.
American Bar Association Commission on Law and Aging & American Psychological Association. (2008). Assessment of older adults with diminished capacity: A handbook for psychologists. Washington, DC: American Bar Association and APA. ABA/APA Assessment of Capacity in Older Adults
American Psychological Association. (2014). Guidelines for Psychological Practice with Older Adults. American Psychologist, 69(1), 34–65. https://doi.org/10.1037/a0035063
Vig, E.K., Starks, H., Taylor, J.S., Hopley, E.K., Fryer-Edwards, K. (2007). Surviving surrogate-decision making: What helps and hampers the experience of making medical decisions for others. Society of General Internal Medicine, 22, 1274-1279.
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Qualls, S. H., & Czirr, R. (1988). Geriatric health teams: Classifying models of professional and team functioning. The Gerontologist, 28, 372-376.
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Mezey, M. D., Cassel, C. D., Bottrell, M. M., Hyer, K., Howe, J. L., & Fulmer, T. T. (Eds.). (2002). Ethical patient care: A casebook for geriatric health care teams. Baltimore, MD: The Johns Hopkins University Press.
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Karel, M. J., Emery, E. E., Molinari, V., & CoPGTP Task Force on the Assessment of Geropsychology Competencies. (2010). Development of a tool to evaluate geropsychology knowledge and skill competencies. International Psychogeriatrics, 22 (6), 886-896.
Karel, M. J., Holley, C. K., Whitbourne, S. K., Segal, D. L., Tazeau, Y. N., Emery, E. E., Molinari, V., Yang, J., & Zweig, R. A. (2012). Preliminary validation of a tool to assess competencies for professional geropsychology practice. Professional Psychology: Research and Practice, 43, 110-117.