Katie Krukenberg is an MSW graduate (2006) from Florida State University and a licensed clinical social worker in North Dakota. She works at the University of Mary and is an assistant professor of social work as well as the director of field education for the social work program.
Students in Florida State University’s online MSW program learn about assessment with all clients, which may include assessing capacity in an effort to be responsive to a client’s needs. Assessing capacity includes determining a person’s level of comprehension when presented with information, their orientation to time and place, cognition and decision making skills, and ability to make their own medical, financial, and legal decisions. The NASW Code of Ethics includes provisions for work with clients lacking decision-making capacity with the following standard: “When social workers act on behalf of clients who lack the capacity to make informed decisions, social workers should take reasonable steps to safeguard the rights of these clients” (standard 1.14). Safeguarding rights as well as ensuring that basic needs for nutrition, housing, health care, and safety are being met may be the primary focus of some social work roles. These are important priorities for all social workers whose clients include vulnerable older adults. Here are three ways that assessment of capacity impacts social work with vulnerable older adults.
1. Ethical Considerations
Within the six core values identified in the preamble of the NASW Code of Ethics is the value of respect for the dignity and worth of the person. The Code of Ethics provides the following guidance with direct relevance to the assessment of capacity and social work practice with vulnerable older adults:
“Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients' socially responsible self-determination. Social workers seek to enhance clients' capacity and opportunity to change and to address their own needs. Social workers are cognizant of their dual responsibility to clients and to the broader society. They seek to resolve conflicts between clients' interests and the broader society's interests in a socially responsible manner consistent with the values, ethical principles, and ethical standards of the profession” (NASW, 2017).
Along with ensuring respect for the dignity and worth of the person, social workers must always be mindful of the client’s right to self-determination. Assessment of capacity becomes an important consideration when considering self-determination. Diminished capacity in a way that jeopardizes safety include situations outlined by the NASW Code of Ethics which may require that a social worker limit a client’s right to self-determination in order to ensure safety for the individual. Reasonable steps must be taken to ensure that the client’s rights are being respected and their safety and physiological needs are being met.
Under the NASW ethical standard pertaining to informed consent, the directive is that social workers protect clients by seeking permission from an appropriate third party when a client is unable to give consent due to diminished capacity. Social workers are to act in a manner consistent with their clients’ wishes and to enhance clients’ ability to give informed consent (standard 1.03c).
2 Evidence-Based Practice
In addition to cognition, assessment of capacity should also factor in mental health or substance abuse factors, medical history, the person’s environment, and appropriate collateral information from those close to the client. Use of assessment tools that are evidence-based and thorough in providing enough information to assess capacity is critical. Any limitations of the tool based on gender, race, or educational status must also be considered when interpreting results, and assessment should accompany a thorough review of all available information in addition to current circumstances. Social workers assessing the capacity of vulnerable older adults may need additional training specific to the settings they are employed in. They may need to ensure that information gathered in the assessment process will meet the need of various entities where such information may become necessary for decision making on behalf of the client, including the court system.
3. Legal Considerations
In addition to ethical considerations and best practice standards, social workers must also be attentive to legal considerations concerning clients with diminished capacity. Many states require mandated reporting of abuse and neglect of vulnerable adults which includes financial exploitation. If a social worker becomes aware of a client who meets the legal or state identified definition of vulnerable adult, this would require that they file a report so that the abuse or neglect can be investigated.
Findings of abuse or neglect can be one pathway to pursuing guardianship options for vulnerable older adults in order to ensure their safety. Other circumstances can warrant the need to assess the appropriateness of pursuing guardianship for a client, and assessing capacity is a critical factor in this process. Because guardianship is a legal process, social workers must be well versed in the process and thorough in ensuring that documentation needed for the court to make a decision on behalf of the client is provided and is adequate to demonstrate the need for guardianship based on lack of capacity resulting in serious safety concerns.
Social workers employed in long term care settings may have a responsibility for ongoing assessment of capacity and may serve as advocates to ensure that the client or guardian’s wishes are being respected in the care of the client. Working to uphold the client’s right to self-determination when possible remains a priority, as well as ensuring that a client’s needs are being met. Social workers in long term care settings may have to help navigate issues such as when it is appropriate to require medication against the client’s wishes or abuse or neglect that occurs within a long term care setting that the client does not wish to report. These are issues in which client capacity becomes a critical factor, and highlight the need for social workers who are educated and knowledgeable about the assessment of capacity for vulnerable older adults.
National Association of Social Workers. (2017). Code of ethics of the National Association of Social Workers. Washington, DC. NASW Press.