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Race, Religion, & Sexuality in Long-Term Care: Understanding Preferences and Building Supports

This article explores the importance of acknowledging individual preferences related to race, religion, and sexuality in long-term care. It provides strategies for accessing appropriate support, engaging family in uncomfortable discussions, and utilizing professional resources. The article also highlights key racial considerations among residents, caregivers, social engagement, and disease diagnoses.

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Race, Religion, & Sexuality in Long-Term Care: Understanding Preferences and Building Supports

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  1. Race Religion & Sexuality in Long-Term Care Bryan J. Adler, Esq. CELA* Rothkoff Law Group

  2. Learning Objectives • Determine individual personal, social, religious and sexual preferences; • Access appropriate long-term care supports; • Engage family in discussions that may be uncomfortable; • Develop resources to aid individual and/or diffuse conflict; • Identify professional resources and when best to use them.

  3. Race

  4. Racial Considerations Roadmap • Current residents • Caregivers • Social engagement • Health status

  5. Racial ConsiderationsCurrent Residents • United States: • 308MM Citizens • 76.6% White; 13.4% Black; 18.1% Hispanic/Latino; 5.8% Asian • 1.4MM Nursing Home Residents • 78% White; 14% Black; 5% Hispanic/Latino; 1.7% Asian • Pennsylvania: • 12.85MM Citizens • 82% White; 11% Black; 7% Hispanic; 2.5% Asian • 80,331 Nursing Home Residents • 87.5% White; 10.5% Black; 1.4% Hispanic/Latino; .4% Asian

  6. Racial Considerations Caregivers • CDC 2004-2005 Nursing Home Study • 702,500 CNAs • 92% Female • 53.4% White; 38.7% Black; 7.9% other • ~75% High School diploma or less • 77% - Family Income below $40,000

  7. Racial ConsiderationsSocial Engagement • Health & Human Services Study • Interaction With Others: 81% White; 76% Black; 70% Hispanic • Establishing Goals: 20% White; 15% Black; 12% Hispanic • Self-Initiates Activities: 51% White; 42% Black; 37% Hispanic

  8. Racial ConsiderationsDisease Diagnoses • Diabetes: 28% White; 43% Black; 44% Hispanic • Cardiovascular Disease: 80% White; 84% Black; 75 Hispanic • Musculoskeletal Disease: 52% White; 38% Black; 37% Hispanic • Dementia: 58% White; 52% Black; 53% Hispanic

  9. Racial Considerations • What do the statistics tell us?

  10. Religion

  11. Religion Roadmap • Protecting beliefs of healthcare workers vs patients’ rights • Respect for patients’ religious preferences

  12. Protecting Religious Beliefs of Healthcare Workers • Roe v. Wade (1973): “Neither physician, hospital, nor hospital personnel shall be required to perform any act violative of personally-held moral principles.”  • Church Amendment (1973): Healthcare providers in certain federally funded programs have the right to object to abortion or sterilization, and sometimes to any procedure, on moral or religious grounds. • Coats-Snowe Amendment (1976): Prevents governmental discrimination against medical entities that decline involvement in abortion training • Burwell v. Hobby Lobby (2014):Closely-held for-profit corporations are exempt from a regulation its owners religiously object to – contraceptive mandate

  13. Protecting Religious Beliefs of Healthcare Workers • Conscience Laws: Permit healthcare providers to not provide certain procedures due to religious or conscious objections • abortion, physician assisted suicide, sex reassignment surgery, withdrawing life-sustaining treatment • HHS forms Conscience and Religious Freedom Division (2018) • Division handles complaints from healthcare workers who do not want to perform medical procedures & creates, new broader enforcement regulations • Prior rule: HHS Office of Civil Rights handles all complaints; no “teeth” • New Regulation (May 2019): • Permits OCR to conduct investigations, compliance reviews, and enforcement with DOJ • Entities must prove in compliance with federal healthcare conscience • Applies to essentially any healthcare entity receiving federal funding

  14. Religious Objections in PracticeAssisted Suicide • Assisted Suicide is legal in 7 states, including New Jersey, Switzerland, Germany, the Netherlands, Australian State of Victoria • Belgium (2016): Catholic long-term care facility fined and sued by decedent’s family for refusing euthanasia • Outcome: Nursing home had no right to refuse euthanasia on the basis of conscientious objection • Hawaii (2018): ACLU send demand letter to a retirement community built on land owned by the catholic church – stop discriminating against non-Catholics and allow medically assisted suicide • Facilities policy revised: IL residents may utilize aid in dying • Residents in the AL and nursing sections cannot access in accord with Hawaii’s aid in dying law

  15. Respecting Patients’ Religious Beliefs Chaplains • Chaplains are the hub of spiritual support and resources in the healthcare industry • 68.5% of American Hospitals have Chaplaincy Services • Association of Professional Chaplains – Board Certification • B.A. and M.A. required, be recognized by religious authority (ordained), one year clinical training, continuing education • Specific Standards for long-term care • Respect diversity, building relationships with local faith communities, individualized spiritual care, educates community about religious and spiritual diversity, understands personal/professional limitations and seeks consultation when needed

  16. Respecting Patients’ Religious BeliefsChaplains • 70% of dying patients want their doctors to as them about their religious beliefs • Only ½ of hospital patients who want spiritual support receive it • Research shows patients who receive support from a chaplain are • Higher quality-of-life scores • More satisfied with their care • Lower rates of hospital deaths and higher rate of hospice enrollments

  17. Respecting Patients’ Religious Beliefs: Diversity in Treatment Preferences • Buddhist: Dietary requirements – vegetarian; nonpharmacological pain management vs meditation; chanting, candles incense at the end of life; reluctance to donate organs – the spirit doesn’t leave the body immediately upon death • Hindu: Modesty is important – same sex caregivers; dietary restrictions – limited or no meat; at death, family washes the body and attends to deceased • Mormon:No alcohol, illicit drugs, caffeine; sickness – two male elders pray over the patient; church tends to encourage maintaining life-support; burial over cremation • Muslim: Modesty – same-sex caregiver; washing before and after meals and prayer; help scheduling prayer five times a day; withdrawing & withholding life-sustaining treatment discouraged; after death – wash body, point face toward mecca; autopsy is rare; burial is immediate

  18. Sexuality

  19. Sexuality Roadmap • Sex in LTC • Capacity • Privacy • Partner gap • STDs • Sexual Orientation in LTC

  20. Seniors are Having Sex • A national survey of men and women 65 to 80 years old found • 40% are sexually active • 54% said sex was important to their quality of life • 73% said they were satisfied with their sex lives • 18% of men and 3% of women took supplements to enhance performance • 67% said they would talk with their health care provider if a problem • 83% had not spoken with a provider in past two years

  21. Sex among Seniors Capacity to Consent • ABA/APA Handbook – Sexual Consent Capacity Assessment • Patient’s awareness of the relationship: • Is the patient aware of who is initiating sexual contact? • Does the patient believe that the other person is a spouse and, thus, acquiesces out of a delusional belief? • Can the patient state what level of sexual intimacy s/he would be comfortable with? • Patient’s ability to avoid exploitation: • Is the behavior consistent with formerly held beliefs/values? • Does the patient have the capacity to say no to uninvited sexual contact? • Patient’s awareness of potential risks: • Does the patient realize that this relationship may be time limited (placement on unit is temporary)? • Can the patient describe how s/he will react when the relationship ends?

  22. Sex Smong Seniors: Capacity to Consent • Neighbors Rehabilitation Center, LLC v. United States Department of Health and Human Services (2018) • 3 residents with dementia engaged in sexual activity. Facility staff believed contact was consensual & balanced residents’ privacy with safety. IL Dept. of Public Health & CMS cited the facility. • Federal Appeals Court upheld CMS citations because the facility failed to • Talk to the residents about their feelings regarding these relationships • Document the residents' capacity for consent; and • Obtain medical assessments of how the residents' cognitive deficits affected their capacity

  23. Sex Among SeniorsPhysical Privacy • Privacy • Education of facility staff on responding to residents’ intimacy and need for it • Providing physical space for intimacy • Educating families

  24. Sex Among SeniorsPartner Gap • Women make up the majority of the senior population • Women live longer than men • Older men, younger women • Societal double standard: older women less attractive than male counterparts

  25. Sex Among SeniorsSTDs • Rising STD & STI rates • Performance enhancing drugs • Summer of Love – 1967; free love generation entering their 70s • 2016 AARP Nationwide Survey: • 3,000 known cases of gonorrhea, syphilis, and chlamydia • 20% increase from prior year • Physicians not screening during wellness exams • Education – increase condom use; seniors did not receive modern sex ed & no AIDS prevention education

  26. Sexual Orientation & Gender IdentityRoadmap • Lesbian, Gay, Bisexual, Transgender (LGBT) • Statistics • Experiences • Changes

  27. Sexual Orientation & Gender IdentityStatistics • 9 MM Americans identify as LGBT • 3 MM Americans 50 or older identify as LGBT • 7MM by 2030 • 2x as likely to live alone • 4x less likely to have kids

  28. Experiences and Attitudes of LGBT Older Adults (45-70) Infographic: sageusa.org

  29. Sexual Orientation & Gender IdentityDiscrimination • 27% LGBT baby boomers express concern about discrimination when they age • Survey of LGBT seniors and their caregivers found • 89% predicted staff discrimination • 81% predicted discrimination by other residents • 53% thought staff would abuse of neglect LGBT senior

  30. Sexual Orientation & Gender IdentityAddressing the Challenges • Modifying healthcare provider intake process to identify LGBT seniors to ensure proper treatment • Need new training, policies, and protocols • LGBT-friendly senior housing and subsidized housing • Ombudsman involvement: educational programs, measures for resident safety & discrimination • AAA: provide resources for LGBT consumers and providers • More research: how can we help?

  31. Resources • A Culture of Racial Discrimination Is Incompatible with a Culture of Health • https://familiesusa.org/blog/2018/04/culture-racial-discrimination-incompatible-culture-health • Assessment of Older Adults with Diminished Capacity: A Handbook for Psychologists (ABA/APA) • https://www.apa.org/images/capacity-psychologist-handbook_tcm7-78003.pdf • Final Conscience Regulation • https://www.hhs.gov/sites/default/files/final-conscience-rule-factsheet.pdf • Standards for Professional Chaplains in Long-Term Care • http://www.professionalchaplains.org/files/professional_standards/standards_of_practice/sop_longtermcare.pdf • SAGE: Advocacy & services for LGBT Elders • www.sageusa.org • LGBT Older Adults in Long-Term Care Facilities: Stories from the Field • https://www.lgbtagingcenter.org/resources/pdfs/NSCLC_LGBT_report.pdf

  32. Wrap-Up • Questions • 2019 Elder Care Symposium • Obtaining CEU credits • Use us as a resource

  33. CHERRY HILL | TURNERSVILLE | HAMILTON RADNOR | TREVOSE | PHILADELPHIA

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