Dear Caregiver

COUNTING ON CAREGIVERS

The Social Side of Caregiving

INTRODUCTION

The need of dependent adults for medical and functional assistance is widely understood and accepted in the caregiving community. The equally important need for caregiver assistance with the social aspects of life and support for dependent adults in maintaining unique identities is less well understood. This booklet, provided for you by Campbell County Department of Social Services and its Adult Services team, addresses the less frequently discussed social side of caregiving, which is crucial to providing quality care. In order to offer a practical, concise resource on the subject we engaged the services of Joy Duke, an expert in the field of social work and human services, particularly as they relate to adults. Using her vast knowledge, experience and research, Joy took a list of needs identified by the Adult team and wrote Counting On Caregivers.

As the Social Work Supervisor for the unit, it is my privilege to work with a dedicated Adult Services team, both on this project and on a daily basis. Social Workers Deronda Brightwell, Julie Williams, Sharmaine Edmunds and Social Work Aide Shirley Pannell consistently lead the way to a life of quality and independence, as our mission statement reads, and it is to them that this booklet is dedicated. Thank you for taking the time to read it; it is our hope that you will be able to apply these principles to your vital role as a professional caregiver.

Susan Rosser Jones

Team Vision Statement: "We envision a community in which the vulnerable are protected, families are strong, and age is embraced and honored."

ABOUT THE AUTHOR

Joy Duke, MSW, is the Executive Director of the Virginia Guardianship Association. She is immediate past chairperson of the Virginia Elder Rights Coalition. She administered Virginia’s Adult Protective Services Program from 1984 until her retirement in 2001.

Ms. Duke is a charter member, and former Board member, of the National Association of Adult Protective Services (NAAPS) and she is the 2001 recipient of the NAAPS Rosalie Wolf Award. She is a charter member and former Board member of the National Committee for the Prevention of Elder Abuse (NCPEA). She founded the Virginia Coalition for the Prevention of Elder Abuse (VCPEA) and is the recipient of the VCPEA lifetime achievement award.

Ms. Duke has conducted and published research both independently and in collaboration with others on topics related to APS, elder abuse, elder sexual abuse, domestic violence in older women and guardianship. She wrote the curriculum for the Virginia Institute for Social Services Training Activities (VISSTA) on Investigating Self- Neglect.

Appointed by Governor Mark Warner to the Public Guardian and Conservator Advisory Board, Ms. Duke was also a Virginia Delegate to the 1995 White House Conference on Aging. She is an experienced family caregiver, a runner, a crossword puzzle enthusiast and a freelance writer who lives in Richmond, VA.

FORWARD

Dear Caregiver:

Welcome to the profession of caregiving. It is noble work you enter into and you will find countless opportunities to show mercy, to act with kindness and to do good. Please know that the work you do is valued. It is important work. It is essential. It is work that enhances life and it is appreciated. In 1995, my husband became dependent following surgery and he needed care the last four years of his life. My family and I decided to take care of him at home. With the passage of time, we have forgotten much of the trauma that occurred at the hospital and many of the crises that filled our lives the next four years. We have never forgotten his caregivers. We have not forgotten their gifts of compassionate care for him and their support of us during those years. It is with a deep sense of gratitude to his caregivers and to all caregivers that I write these words of appreciation for all you do for dependent adults1 and their families.

It is my hope that you will find your work deeply rewarding. I hope you will know the joy and satisfaction that come with having a job worth doing and doing the job well. I hope the recipients of your care will know your compassion, your kindness and your patience. The work you do makes a difference in the lives of individuals and families, and communities. It makes the world a better place.

Mother Theresa said,”We cannot do great things on this earth. We can only do small things with great love.” In caregiving, doing small things with great love is a very large gift. If you approach each person you serve with kindness, patience, compassion and love, the ripples of hope you send forth will change the world for each of those persons. Thank you on their behalf.

Counting on Caregivers

Without regard to how wealthy or frugal we have been all our lives, without regard to how loving we have been or how much good we have done for other people, it is possible that any of us may outlive family who would otherwise care for us in old age. It is possible that any of us may reach a point in life when we are no longer able to manage our lives in a way that has always been routine for us. It can be a frightening and helpless feeling, as we face the uncertainty of how our basic needs will be met when we can no longer manage on our own.

In the event any of us find ourselves in a position of depending on other people for the care we need, we can probably agree on certain things that we would want. Even though we may be dependent on others for care, we would want our caregivers to help us help ourselves to be as independent as we can possibly be. We would want those who are responsible for our care to see to it that we receive appropriate medical care and we would want timely and comfortable and compassionate personal care. We would want our preferences to be respected to the extent possible even if our preferences seem trivial or unimportant to other people. We would want our human rights protected. Human rights include, but are not limited to, the right to be treated with dignity and respect, the right to be treated equally under the law, the freedom to express our thoughts and ideas, and the right to life and liberty. Perhaps, most of all, we would want kindness. Those are some of the things we would most want from those who assume responsibility for our care. To know what to do and what not to do for a dependent adult, it is necessary to understand what life is like from the dependent person’s point of view.

Dependence changes lives in two basic ways. It changes how the dependent adult spends time and it changes how she2 relates to other people. An adult who becomes dependent remembers a life of activity and finds herself spending large parts of days waiting. Waiting becomes a way of life – waiting for a meal to be served; waiting for the caregiver to arrive to begin the day’s routine; waiting for a ride to be driven to a medical appointment or to church; waiting for mail to be delivered; waiting for someone to bring the paper inside; waiting for a visitor who mentioned she might come by today; waiting for someone or something to break up the monotony of the day. The more dependent a person is, the more time she spends waiting.3

Two men live in a near-by senior housing complex, each in his eighties. I drive these two men to church on Sundays arriving at the lobby of their building at 10:30. They take care 4 not to keep me waiting. They arrive in the lobby at 10:00, perhaps out of consideration for my time, perhaps out of an understanding that they are depending on kindness and they are fearful that the kindness is not unconditional. Perhaps they are not sure they are worth “all this trouble” and are concerned that I may reach the same conclusion. Perhaps they are concerned about using up the good will. Dependence damages one’s feelings of self-worth. This brief sketch illustrates the sense of inequality that exists between two men who are dependent on me to get to church and I who am not dependent on them. They have time to wait; whereas, I must schedule time to drive by and give them a ride.

Perhaps the most difficult part of waiting is the attention it draws to the status of the dependent person as one who has lost or surrendered her power to another person. Anyone who has been left sitting in a doctor’s office long after appointment time has come and gone will be able to identify with the kinds of feelings called forth by waiting.

In relationships with family, with friends, and with other people, the dependent adult becomes the recipient of good will and often it is good will that she cannot return. The dependent person becomes concerned if she goes to the well too often, the good will may dry up and she conducts relationships with this fear fixed firmly in her mind. The balance of relationships has changed.

Let There be Honor4

What does it mean to honor the person for whom you provide care? Sometimes when we use the word honor, we use it as an obligation, as in “honor thy father and thy mother”. Sometimes we think of honor as an award for some accomplishment, as in an awards luncheon for volunteers who have contributed their time and energy to a cause. However, when we speak of honor in a caregiving setting, we are making reference to something far more private that an award ceremony held in a public place.

In a caregiving context, the word honor implies that a bond exists between the caregiver and the care recipient. It implies that a caregiver recognizes the care recipient as symbolic of all who may one day need care. It implies that honoring one of us who needs care honors all of us who may one day need care. Helping a dependent person with a bath or with other personal tasks may never get you an awards luncheon but, when that bath or personal help is given with compassion and kindness, it is nonetheless a remarkable gift. It is an expression of honor.

We have talked about the importance of being sensitive to the changed status of the person who was once an independent adult and who now needs your care. When you understand and appreciate how difficult the life changes are for the person who has become dependent, this too is a part of honoring. Kindness is a part of what it means to honor. Respectfulness is a part of honor. Small things given with great love are honorable.

In the role of a caregiver, honor includes many elements but perhaps most significantly, honoring a dependent adult means doing what you do in a way that supports the life she chooses to live. When you care for a dependent person, you do much more than help 5 her survive another day as comfortably as possible. As a caregiver you are there at a time during which an adult is very vulnerable. You are there not to take control of her life but rather to support, assist, and do whatever possible to help her retain control of her life to the greatest extent possible.

I am a social worker and in social work we sometimes talk about “the right to folly.” What we generally mean by this phrase is that a competent adult has the right to her own behavior and decisions, even foolish behavior and decisions, if what she proposes and does is not illegal and if it does not harm self or put other people at risk. Your most prized gift to the adult for whom you provide care may be helping her hold on to her pride. Maya Angelou, the poet, is quoted as saying, “People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

Foundation of Effective Caregiving

Effective caregiving of elders and adults with disabilities begins with the development of a relationship between the caregiver and dependent adult. As the caregiver begins to build a relationship she should be aware that, for dependent adults, a relationship is built first on respect for old age or for the difficulties of living with disabilities, as the case may be. For elders, the building of a helping relationship must begin with deeply held beliefs that:

o old age is an important stage in the life cycle; o elders have made and continue to make important contributions to the lives of others and to the world as a whole; and o each person who comes to you has a right to your care and is worth helping and is entitled to the best care you have to give.

For younger adults with disabilities the relationship building must begin with:

o respect for the difficulties of adjusting and coping with life lived with disabilities; o an acknowledgement of the contributions that this adult and her peers have to offer to other people and to society as a whole; and o an appreciation of this adult’s right to, entitlement to, and worthiness of care

Assurance to the dependent adult that she is valued and respected is essential to the relationship. This assurance comes less from being told that one is valued and respected and more from being shown. Honesty, trust, and other ethical behaviors are important parts of the helping relationship.

The building of the helping relationship is more difficult because of the imbalance of power between the caregiver and the person receiving care. The caregiver is assuming power that previously belonged to the dependent person. Sometimes the dependent person gives up power in exchange for care. The adult who depends on the good will and care of another person for her very life may feel that she stands on shaky ground.

6 When a dependent person reacts in a way that is angry, resentful, or anxious, it may be that she is experiencing grief and anxiety at her loss of power and control and is expressing feelings about the loss the only way she knows how.

Before a dependent adult can enter into a helping relationship with a caregiver, she will need to trust the caregiver not to abuse the power and control that has been entrusted to her. For all of us, it is our nature to trust people who trust us. We are more trusting of people who ask our opinions and are interested in what we have to say. We tend to trust people who care about things we care about, such as family, health, perhaps church, perhaps pets and other things that are important to us. We trust people who know our flaws and accept us flaws and all. We trust people who answer our questions simply and without judgment. We trust those who go the extra mile and do things for us they don’t have to do.

How you speak to persons to whom you provide care, the words your use, the tone of your voice, your facial expression, whether you make eye contract, as well as messages your behavior may send, these things either help or harm your effort to develop the relationship.

The following list of dos and don’ts may be helpful as you begin building a caregiving – care recipient relationship:

Things to do......

o DO take care of yourself. This publication has not dealt with this area of responsibility. However, without self care the quality of your caregiving will be compromised. Consider the airline approach to self care. Before the aircraft leaves the ground, airline personnel instructs passengers on what action to take if there is a problem during flight. Passengers are told in case the cabin becomes depressurized an oxygen mask will drop in front of you. If you are traveling with someone who needs help with the oxygen mask, first, you are told, put your own mask on. When your mask is in place, then help the other person. Something similar is true in caregiving. First see to your own health and welfare. You will then be better able to see to the needs of other people.

o DO pace yourself; if you find yourself becoming overwhelmed with caregiving situations, talk with your supervisor about ways you may deal with the stress.

o DO watch for hidden blessings in the work that you do. You may even want to write them down. You will be amazed at how the blessings flood in if you are open to receiving them.

o DO take responsibility for yourself, for the caregiving decisions you make and for the quality of the work you do. Your responsibility is to do your job to the best of your ability.

o DO be clear with those for whom you provide care about why you are there and what jobs you are responsible for managing. For example, if the person for whom you provide care asks for your help with writing checks or other aspects of financial management, and if you are not authorized to help in this area, let the person know this is not your role. You may want to talk with your supervisor about how any unmet needs that come to your attention should be handled.

o DO become familiar with signs of abuse and neglect and financial exploitation and report any suspicion to adult protective services (APS) at the local department of social services or at the APS toll free number 1-888-832-3858. The social worker at the local department of social services can provide you with a list of signs that suggest mistreatment may be occurring.

o DO take advantage of opportunities to attend seminars, read or use other methods to learn more about caregiving and the role caregivers play in the health care system.

Things to avoid doing.....

o DON’T allow yourself to become involved in disagreements within a dependent adult’s family. A family member who disagrees with other family members about whether mother should be in a nursing home, or about mother’s financial affairs or other conflicts, may want to win your support for her position. Your job does not include resolving or taking a position in family conflicts.

o DON’T bring frustrations and problems from home to the job. Just as you leave problems at work behind when you leave the job, also leave your family problems at home when you go to the job.

o DON’T accept money or other gifts from a person for whom you provide care (no exceptions). This assumes that you are not being paid directly by the care recipient but rather by a third party; e.g. the local department of social services that recruited you, the nursing home or assisted living facility where you work, or some other third party payer. Dependent adults are understandably anxious about abandonment by the person on whom they rely for care. Sometimes they use money or other gifts as a way of trying to buy favor, of decreasing their anxiety about being abandoned. Accepting such gifts under some circumstances may be considered financial abuse.

o DON’T discuss with care recipients your own financial problems or the financial problems of other members of your family. Do not discuss any topic that may cause a recipient of care to wonder if you are asking for or needing financial help. This too can stir those fears of abandonment if help is not given. The rule is to

8 neither request nor accept gifts from people for whom you provide personal care services.

o DON’T leave the dependent adult out of decisions to be made about her daily life and routine. No doubt it saves time and effort to make the decision yourself and get on with getting the job done, but caregiving is not about saving time.

o DON’T impose your personal views and values on others. Your views and values and those of your care recipient may differ on such topics as religion, politics, social issues, child rearing, pets, and any number of other issues. It is more fruitful to celebrate the differences that to attempt to change another person’s values. We each have values we have built over our life times and we have a right to those values. We don’t have a right to project our values and standards on others.

o DON’T overlook the fact that a dependent adult may be grieving. Elders and adults with disabilities experience many losses, some of which come close together and in a short period of time. The loss of health, the loss of ability to care for self, the loss of family members and friends either through death or lack of contact, the loss of ability to get out and enjoy a social life are just a few of the losses that are commonly experienced by adults who become dependent.

Ethics of Caregiving5

Ethics means doing the right thing. There are times in a caregiver’s practice when the right thing to do may not be immediately clear. The following seven ethical principles can be helpful when confronted with questions and indecision about the right thing to do.

o An adult has the right to direct her own life. She has the right to make decisions, both large and small, for herself and to make those decisions without pressure from other people. Sometimes decisions are far-reaching, as in writing a will or drawing up an advance directive or having surgery. Sometimes decisions are routine, as in what to have for dinner, whether to attend church, or what time to go to bed. One might express this principle as “This is my life and I am in charge,” or perhaps as “I am the boss of me.” As adults, we all have the right to be in charge of our lives and the paths our lives will take. Disability, dependence, age, impoverishment and other conditions do not take away the right to be in charge of self. The dependent person, while able to make decisions for self, may not be able to act on those decisions. A caregiver’s responsibility is guided by the decisions made by the dependent adult. The dependent adult is the person to whom the caregiver owes allegiance (has a duty). The dependent adult’s family may or may not agree with the dependent adult’s decisions. The caregiver does not owe allegiance to the family. Others in the community may have values that differ from the values of the dependent adult. Community opinions on what is

9 in the best interest of the dependent adult may differ from decisions made by that adult. In this situation, the caregiver does not owe allegiance to the community.

It is important to remember that the adult is in charge of decision making for self until she delegates this responsibility voluntarily to another person or until a court grants responsibility to another person. o Doing good for others is an ethical principle. This principle is especially emphasized in the fields of medicine, nursing, psychology, social work and other professions that work directly with people. It means people who need care have a right to receive care from others and, as a caregiver, your responsibility is to do those tasks which support or improve the welfare of adults in your care. It also means to avoid doing things that are not in the best interest of the adult care recipient.

As a caregiver, doing good for others is a big part of how you spend your work day. Doing good means doing the job with kindness. Look for opportunities to transform routine daily chores into acts of kindness. For example, for people who are homebound, making meal times special is a kindness. Meals break the monotony of the day and are occasions a caregiver can use to create a special time. This might include preparing the adult’s favorite dish, using an attractive tablecloth or place mat and perhaps placing a flower on the table. It may include asking the adult to suggest a recipe or explain how she made a certain dish.

As you go about your caregiving responsibilities, whether you are doing the laundry, changing linen, cleaning floors, preparing meals or doing any of the other countless tasks that in-home caregiver do every day, what you are in fact doing is supporting the life a dependent adult is living. You are doing the job that adult would do for self if she were able to take over the job. To the degree possible, your job is to do her job the way she wants it done. It is doing small things with great love that makes the difference.

Take time each day to talk with the person for who you provide care. Yours may be the only voice she hears that day. Be patient and listen to what she wants to say. Whatever feelings she may express, she has a right to how she feels. While small acts meant to cheer are good, trying to talk a person out of her feelings is not recommended. o Do no harm. Just as there is an ethical principle that says, “Do good for others,” there is also an ethical principle that says, “First, do no harm.” On the surface this seems obvious since it is your purpose is to do good and not to do harm. However, sometimes the decision to be made, and whether it will bring help or harm, is not all that clear. Sometimes there is a thin line between intervening (a good thing) and interfering (not a good thing).

10 Let’s look at an example of good intentions gone wrong:

Molly, an 81 year old woman who lived alone and needed assistance with meal preparation and personal hygiene, as well as other activities of daily living, was a client of the local department of social services. An agency approved caregiver was available to provide care to Molly for ten hours a week. The caregiver’s responsibilities included assisting with a bath at least two times a week, preparing some meals, and doing other light housework. Molly had a reputation for being difficult when it came to bathing. A neighbor who came by infrequently reported to the social worker that Molly seems not to have been bathed in several days and is looking unkempt. The social worker spoke with the caregiver about bathing and the caregiver acknowledged it had been several days since Molly had a bath. The caregiver arrived at Molly’s home the following day with a plan she believed would win the battle of the bath. She thought if she approached Molly directly about the bath, cheerfully and with kindness, if she took care of the bath first before Molly got tired, and if she promised Molly her favorite breakfast following the bath, Molly would be more inclined to cooperate. When bath time came, Molly was not as cooperative with the bath as her caregiver had hoped. The caregiver felt under pressure to give Molly a bath since a complaint had been made about this need. The caregiver felt she was as gentle as she could be with the bath but it was quite a struggle and at time she had to hold Molly down while she continued with the bath. The following morning, Molly telephoned her neighbor and reported difficulty breathing and pain. She was unable to get out of bed unassisted. After visiting with Molly the neighbor was concerned and called for help to get Molly to the hospital. Upon examination it was discovered that Molly had severe bruising and a fractured rib. It was not the outcome the caregiver had planned nor for which she had hoped.

First, do no harm. Harm done is not always physical harm. Sometimes harm involves taking away the dependent person’s right to make decisions and have those decisions respected. Sometimes harm involves making hurtful statements to the person or saying hurtful things about her or people she loves. A dependent adult who lived in an assisted living facility remembered with great pride her life as the wife of a doctor. A caregiver in the facility taunted the woman by saying to her, “No one believes your husband was a doctor.” The caregiver was engaging in mean-spirited behavior that was harmful to the dependent adult’s sense of self worth and was intended to diminish her pride. o Set a standard of fairness. Fairness as an ethical principle, implies treating people in a way that can reasonably be considered just. As applied to the caregiving setting, being fair means to treat all people under your care with open- handedness, open-heartedness, generosity of spirit, kindness and concern for the person and her well-being. It means giving to individuals a fair share of your time and effort and the parts of yourself that represent the best you have to give to another person. It means bringing to the job a pleasant disposition, a friendly smile, a giving and agreeable approach to helping, a respectful attitude, professional on-the-job behavior, absolute honesty, and doing the best you can do to support the life this adult has chosen to live. While on the job, it means being industrious and diligent in the interest of the dependent adult. It means giving a fair day’s work in return for the wages you receive.

11 Consider the adults you work with as “…fellow travelers who have gone a journey that you too may have to go and from whom you can learn whether the road ahead be smooth and easy or rugged and difficult.”6 o Honor Personal Privacy. Kahlil Gibran, the poet, wrote, “Let there be space in your togetherness.”7 We can all identify with the feeling he expresses. While I enjoy your company, I really need some time alone. Be aware that some of us are energized, our minds are stimulated and ideas take root when we spend time alone. Such private time need not be denied to adults who are dependent and who crave private time. They too need time to give birth to new ideas and to reflect on their life experiences. Dependent people sometimes have the opposite problem. People, not knowing what to say, leave them to themselves too much. There needs to be a balance.

The other side of the right to privacy, as an ethical consideration, means that adults have the right to have control over information about themselves. It is an adult’s decision about whether to or not to share information about herself. The person to whom a letter is written or who is the subject of a report or other documents has the right to control that information. As a person who spends time in the dependent person’s home you may come across personal information, or the dependent person may share personal information with you. Such information is to be considered confidential. It is not appropriate for a caregiver to share such information with her own family or friends. This principle may be expressed as “what is learned on the job, stays on the job”. o Be faithful on the job. The principle of faithfulness means that a dependent person has the right to expect her caregiver to show loyalty when it comes to providing help. Loyalty, or faithfulness, means showing up for work as scheduled. It means doing those things for the dependent adult that have been identified as the tasks than need doing to support the care recipient’s best interest. It means doing the job to the best of your abilities. It means doing special things that make life just a little better for the dependent person. It means bringing your best self to the job. o Accountability for one’s self is an ethical principle. It means taking responsibility for the decisions you make and for the actions you take. Sometimes accountability means taking responsibility for failure to take action when action is needed. It means knowing when to call for help. It means conducting your professional life in such a way that you have nothing to hide. It means your employers can count on you to do the job you are being paid to do and to do it to the best of your ability. It means your care recipients, your employer, and others with whom your work can count on you to be truthful. It means you accept responsibility to expose others whose irresponsibility and deception put dependent adults at risk.

Thanks to You for All You Do

To caregivers everywhere, thank you for all you do. These things I know are true:

o People with disabling conditions, families of people with age related impairments as well as families of people whose disabilities are unrelated to aging, and the entire health care system of the nation depend on the kindness, the dedication, the expertise and the availability of caregivers. Thank you for your commitment to caring.

o People who give themselves and their professional lives to the physical care of others have noble spirits. They see the need for someone to help and they say, “Why not me?” They see suffering and try to ease it. Each time a caregiver acts to improve the lot of another person, she sends forth tiny ripples of hope and the recipient who is depending on kindness feels less alone, less despair and greater promise. Thank you for the hope you bring to others.

o The late Vice President Hubert Humphrey once said that social progress should be measured by how we care for those in the dawn of life, the children; those in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the disabled. It is into this realm of service that you, a caregiver, enter and it is you, a caregiver, who is in a position to help the nation realize the social progress to which Vice President Humphrey referred. Thank you for your contribution to a better world.

o We take ourselves with us as we age. How we learn to care for, feel about, and honor aged people; and attitudes we develop toward aging and dependence will have much to do with our attitudes about our own aging and how we face frailty and dependence in ourselves. Therefore, in a sense, the good we do for others we do for ourselves.8

Notes

1 Throughout this manuscript the words “dependent adult,” and “dependent person,” are used interchangeably. In each situation, reference is being made to the person for whom a caregiver is providing care.

2 Throughout this manuscript the feminine gender “she” or “her” is used to make reference to the dependent adult or dependent person, without regard to whether the person being referenced is male or female. Likewise, the feminine gender is used in making reference to the caregiver. We acknowledge

13 that caregivers as well as clients may be either male or female. This method of using one gender is used to avoid the repetitive use of his/her.

3 While the final responsibility for this discussion on waiting is mine, I am indebted to Wendy Lustbader for her discussions of “waiting” and “mercy” in her book, Counting On Kindness, The Dilemmas of Dependence (1991). Her discussions were the inspiration for this segment.

4 While the final responsibility for the discussion is mine, Beth Witrogen McLeon’s discussion of honor, in her book, And Thou Shalt Honor, The Caregiver’s Companion (2002), was very useful in helping me to think through issues of honor.

5 The seven ethical principles discussed here are outlined by Tanya Johnson, PhD, and Rosalie Wolf, PhD, in a training manual which they wrote for the National Center on Elder Abuse. These are the same ethical principles widely used throughout a spectrum of medical and human services professions. The manual by Drs. Johnson and Wolf is called Elder Mistreatment: Ethical Issues, Dilemmas, and Decision- Making (1998). For the purposes of this publication, discussion of each of the seven principles was revised to highlight its applicability to caregivers.

6 This is a quotation from Socrates, a part of his discussion on aged men, as reported by Plato in The Republic. The Republic can be found in The Potable Plato (1948).

7 This is a quotation from Kahil Gibran’s book, The Prophet

8 Discussed in Beth Witrogen McLeon’s book And Thou Shalt Honor, The Caregiver’s Companion (2002)

Notes

2 Throughout this manuscript the feminine gender “she” or “her” is used to make reference to the client or dependent adult or dependent person, without regard to whether the person being referenced is male or female. Likewise, the feminine gender is used in making reference to the caregiver. We acknowledge that caregivers as well as clients may be either male or female. This method of using one gender is used to avoid the repetitive use of his/her.

4 While the final responsibility for the discussion of honor is mine, Beth Witrogen McLeon’s discussion of honor, in her book, And Thou Shalt Honor, The Caregiver’s Companion (2002), was very useful in helping me to think through issues of honor. I have used her title as a heading of this section and for naming this publication.

5 The seven ethical principles discussed here are outlined by Tanya Johnson, PhD, and Rosalie Wolf, PhD, in a training manual which they wrote for the National Center on Elder Abuse. These are the same ethical principles widely used throughout a spectrum of medical and human services professions. The manual by Drs. Johnson and Wolf is called Elder Mistreatment: Ethical Issues, Dilemnas, and Decision- Making (1998). For the purposes of this publication, discussion of each of the seven principles was revised to highlight its applicability to caregivers.

6 This is a quotation from Socrates, a part of his discussion on aged men, as reported by Plato in The Republic. The Republic can be found in The Potable Plato (1948).

7 This is a quotation from Kahil Gibran’s book, The Prophet (1923).

8 Discussed by Beth Witrogen McLeon in And Thou Shalt Honor, The Caregiver’s Companion (2002)