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According to Schwiebert, current ACA (1995) ethical standards do not provide adequate guidelines for working with older adults who have cognitive impairments. More specifically, the informed consent stasndards seem inadequate. The ACA standards state that a guardian or other appointed legal representative can give consent for a person unable to give such consent himself or herself. The question then becomes when is a person unable to give such consent. This may be an even more complex question when a progressively deteriorating mental condition, such as Alzheimer's disease, is present. The counselor may begin working with the client during the beginning stages of such a disease, and as the disease progresses, it may no longer be clear that the individual can give truly informed consent to remain in therapy (Myers & Schwiebert, 1996; Netting & Williams, 1989). In this case, it is important that the counselor be familiar with screening instruments such as the Mini Mental Status Exam (Folstein, 1998) and other measures of cognitive impairment. The counselor must also know the limitations of the instruments when working with older adults.
Another dilemma might be the client's inability to remain in a safe, independent living environment due to his or her deteriorating condition despite his or her wishes to remain in that environment. Other mental conditions may cause intermittent periods of confusion and disorientation that would impede a client's consistent ability to give informed consent or make sound decisions. (Myers & Schwiebert, 1996). These dilemmas raise questions such as the following: Does this mean the counselor can no longer treat the client? Does the counselor need to wait until a legal guardian has been appointed for the client before they can begin providing services? Does the counselor have the obligation to initiate steps to move the client to more supportive housing when it is clear the client can no longer remain in an independent living situation safely, despite his or her wishes to do so?
In addition to the client being a danger to himself or herself, issues may arise when the counselor must evaluate if the client is a danger to others. If a client has a cognitive impairment and the counselor believes he or she is a danger to others when driving, what is the counselor's obligation? If an older person has a cognitive impairment and is caring for a bedridden spouse, is the individual a danger to that person if he or she can no longer remember to do such tasks as turning off the stove? The counselor must make ethical judgments about maximizing independence (autonomy) while preventing harm (beneficence).
On the basis of the ethical guidelines just discussed, what is the counselor's obligation? First, the client's best interest must be maintained. Therefore, the counselor must first determine if, in fact, the client has a progressively deteriorating condition that cannot be expected to improve with treatment. A thorough and accurate geriatric assessment by a qualified physician is the first step in this process. Once a medical diagnosis of advanced Alzheimer's disease has been made, the counselor's interventions must be guided by the ethical principles that the client's best interest is to be maintained and that the client is not a harm to herself. This may involve discussions with the client and family members as to what is best for all involved. The counselor can then facilitate appropriate decision making that maintains, to the extent possible, the rights and dignity of all individuals involved (Doolittle & Herrick, 1992; Myers & Schwiebert, 1996).
Another ethical dilemma that counselors may encounter when conducting research involving older adults with cognitive impairments is the need to obtain informed consent for participation in the research (Vonthron Good & Rodrigues-Fisher, 1993). An easy answer to this dilemma may seem to be excluding clients with cognitive impairments from research studies. This seemingly straightforward answer is complicated by the fact that without research it may be impossible to find effective treatment strategies for their particular impairment, thus limiting the clients' rights to options that may be in their best interest. Counselors who are conducting studies that potentially involve clients with cognitive impairments must be guided by the principles of maintaining client dignity and doing no harm to the client (Milliken, 1993). Steps to help ensure that the best interests of the clients are maintained include a clear statement and understanding of the research and the potential benefits and dangers associated with it. Second, an independent review board of individuals knowledgeable about the fields of research and the older population should thoroughly examine the research and its potential benefits and liabilities to determine if the risks outweigh the benefits for older adults and how the potential risks may be minimized. Finally, the counselor engaged in research with older adults who have cognitive impairments must realize that, ultimately, the best safeguard for the client is a competent, informed, and compassionate counselor (Milliken, 1993; Netting & Williams, 1989; Ochroch, 1990).
Although this article could not possibly address every situation involving ethical dilemmas faced by counselors working with older adults, we hope that the guidelines and strategies will provide guidance for counselors in areas in which few or no guidelines currently exist. Counselors working with older adults may wish to include references to the ethical principles defined by Fitting (1986) in their declaration statements. This may help older clients to understand the importance of autonomy, beneficence, and fidelity in the counseling relationship.
As the population continues to age and new legislation is developed, new ethical dilemmas may occur for which no ethical guidelines exist or for which the ethical guidelines may change. Therefore, it is critical that counselors working with older adults stay abreast of the current issues, trends, and legislation related to counseling older adults and that counselors understand the impact these changes may have on ethical counseling with this population.
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