Mr Goh

The ‘bystander effect’ refers to situations in which a person sees another person in distress, but does not take action because like himself, other people are also witnessing the same situation. It is psychologically easier for us to conclude that we need not get involved if we see others who could take action. But if every bystander rationalises inaction – i.e. it’s okay if I don’t get involved, because someone else surely will – then no one may act.

Mr Rasheed is a bystander to what he perceives as a customer’s difficult situation. He and Mr Goh have a daily routine; he brings Mr Goh’s breakfast without Mr Goh having to queue up to order it. Mr Rasheed sees Mr Goh’s daughter briefly each morning. He knows that she returns at the end of her workday to escort her father home. (It is unclear whether father and daughter live in the same household or separately.) Mr Rasheed sees Mr Goh during the day, but probably has little time to chat, or to leave his stall, as he and his nephews attend to their other customers.

When Mr Rasheed describes Mr Goh as a ‘poor old uncle, stuck here day after day’, and says to Hakim, ‘I don’t know if this is right… is it safe’, he seems to question Goh Ying Ying’s judgement, while also wondering whether he should get involved. From his perspective, Mr Rasheed sees a family caregiver with a full-time job to which she must report on time, who has decided that the local food centre is a safe, low-cost place for a frail elderly person to spend the day, and where the hawkers will keep an eye on her father. It is possible that Mr Rasheed sees the arrangement as reflecting Mr Goh’s choice of how to spend his days, but the word ‘stuck’ suggests that Mr Rasheed perceives Ying Ying to be in charge.

Observing Mr Goh’s frailty, Mr Rasheed is feeling mixed emotions. He has his own ‘family business’ to attend to every day, and he is reluctant to get involved in the Gohs’ business. Yet he seems also to resist the bystander effect of seeing a problem and assuming someone else will solve it.

So, what should this good bystander do?

The answer to this question should not depend on whether or not a society mandates members of the public, or specific individuals such as healthcare professionals, to report elder abuse or neglect, or even whether a society encourages members of the public to voluntarily make such reports. (The other commentary on this case addresses these policy considerations.) Mr Rasheed is considering whether he should take some action – beyond asking Mr Goh himself if he is okay – to alert someone to his concerns that Mr Goh’s frailty makes this familiar public setting unsafe. He asks, ‘Maybe I should call someone?’ but his sense of whether to act, as well as what action to take, exactly, would help Mr Goh, remains unresolved. He expects to see Mr Goh again tomorrow.

So, perhaps the question is, what should the community do for Mr Rasheed?

Specifically, what should governmental and private efforts to support ageing people in the community do for community members who are not directly responsible for an ageing person’s welfare and care, but are intrinsic to how hospitable a community is to ageing people and caregivers? Hawkers, shopkeepers, and bus drivers are examples of community members who interact daily with elders in the community. In dense cities like Singapore, food centres and other local businesses are often housed in or close to HDB blocks, making them part of a resident’s familiar environment.

This case does not reveal why Mr Goh spends each day at the food centre. That he is alone, or that he is not at home, does not, on their own, mean he is being neglected. Like people of different ages, he may enjoy observing everyday urban life. His small daily rituals of tea and coffee, and the courtesy of Mr Rasheed, may matter a great deal to him. Or, his daughter may be giving him no choice, or may have no other choice to give him.

Mr Rasheed has observed enough to be concerned about Mr Goh’s basic safety, and it would help him to have somewhere to turn with these concerns. A social service organisation that serves HDB residents might be one place to turn, if an organisation is accessible and trusted by hawkers and other local merchants. The organisation, in turn, may be able to reach out to Ying Ying and her father, to see if help is needed or desired.

In this case, Mr Rasheed is in a difficult position. He observes that Mr Goh is at the food centre each day, but he is unclear about whether Mr Goh is being neglected by his daughter or is simply choosing to spend each day there. He is hesitant to involve himself in another family’s affairs, but he worries about the consequences for Mr Goh if no one checks in on the situation and wonders whether he should call someone.

Mr Rasheed’s response is not surprising. Even among healthcare professionals, there is often great reluctance to report suspected elder abuse or elder neglect because the evidence of these problems can be very subtle, the older person may often deny that they are suffering, and the healthcare professionals often don’t understand reporting procedures. Furthermore, health care professionals may worry that raising these concerns, in the interest of a patient’s welfare, will anger family members and make it more challenging to have a constructive, trusting relationship.

In her commentary, Nancy Berlinger asks what the government and private efforts to support ageing people should do for Mr Rasheed and other members of the community who are in situations of this sort. This is an important question because the situation is common in ageing societies like Singapore. Local food centres and other local businesses are often gathering places for older people in the community. Local businesses offer opportunities for older people to remain engaged in their communities and provide safe spaces in which to interact with others. In Singapore, food centres are important centres of social life and attractive destinations for people of all ages. Vendors who work at these centres frequently encounter older people in the community and may be in an excellent position to identify cases that ought to be investigated by professional social welfare organisations. At the same time, it would be inappropriate to suggest that local business people can or should intervene directly. It is not necessarily a problem or a case of ‘neglect’ when an older person is alone at a hawker stand each day. Indeed, it seems clear that Mr Rasheed does not know whether he is witnessing an example of independence on the part of an older person who is happy to spend his day out in the community at the food centre or a case of neglect by family members who are unable or unwilling to provide a safer or more supportive alternative.

Because Mr Rasheed is not a professional trained to conduct such an assessment, it may be wise for him to avoid making assumptions about the situation and, instead, contact an organisation with the capacity to do so. Fortunately, Singapore has several organisations that can offer this type of assistance to Mr Rasheed and other members of the community. In addition to contacting the Ministry of Social and Family Development (MSF) or the police directly, organisations like Trans Safe Centre, Pave and Care Corner Project Start all provide services for victims of elder abuse and neglect, including self-neglect – and these organisations have hotlines that members of the public may call to report concerns. When social workers at these organisations are contacted by members of the community about suspected cases of abuse, neglect, or self-neglect they will often try to contact the older person and their family members to offer help.

There is growing recognition by MSF and the Ministry of Health that elder abuse and neglect can be prevented by offering support to family caregivers. If they suspect a problem, they may be able to take appropriate action. In some cases, these organisations may be able to offer direct support, including adult-day care programmes, or they may be able to link the older person and the family with other existing programmes and resources. In other cases, however, professional organisations may be rebuffed by the older person or family members and they may not have the opportunity to conduct a proper assessment. One of the issues under debate in the Vulnerable Adults Bill is whether the state ought to have authority, in cases of suspected abuse or neglect, to conduct an assessment – and perhaps even a relocation of a vulnerable older adult – without the consent of the family. Even if this bill is enacted, it will not resolve the question of when the MSF ought to use the power to intervene.

Professionals in geriatric medicine and social work continue to refine assessment tools that allow them to identify cases of abuse and neglect – and there is an ongoing debate about the adequacy of existing tools. Beyond the capacity of professionals to identify cases in which older people are at risk, decisions about when to use the power of the state to intervene will require a careful balance between the obligation to protect vulnerable older people and the desire to respect the dignity of older people and their family relationships.

Food centres in HDB estates are favourite places for seniors. It is a place to meet friends, or be in readily accessible surroundings among familiar people. Retirees can enjoy affordable meals there as they socialise. It is not surprising that Goh Ying Ying and her father have chosen this setting as an option for keeping him occupied during the day while she is at work and finds it harder to take care of him. Perhaps she thinks that he is able to look after his needs independently in this setting. Or she may feel that his ability to care for himself is declining, but that they are unaware of any other option: it’s either this or her father has to go to a nursing home.

With appropriate support, assessment, and intervention, it is possible to enable Mr Goh to continue living in the community, with a say in managing the quality of his life. Caregiver support for Ying Ying could be built around her schedule, by identifying community resources such as day activity centres or day care centres (if he has greater care needs), and neighbours or community befriender services who could take him to these facilities when he wishes to take part. Coordinating befriender or neighbours’ assistance to Mr Goh, and perhaps accompanying him on regular health checks or medical appointments, would relieve some of the stresses Ying Ying faces; it would mean she is able to rely on regular help and affordable services in the care of her father.

As the Gohs have not shown interest in socialising with Mr Rasheed or any others he knows of, Mr Rasheed may find it useful to contact the residents’ committee office, social service office or the community centre to alert them if he notices in Mr Goh any loss of appetite, loss of muscle mass and function/performance (sarcopenia) and frailty, untreated physical problems, unkempt appearance, or distress. As Mr Rasheed makes this first move, he would also gain knowledge and confidence from community professionals on how members of the public can support elders in the community.

These community agencies would approach the network of voluntary welfare organisations in their vicinity to find out if Mr Goh is already an existing client with whom they can re-establish contact. If it is not the case, community agencies would then identify trained counsellors to approach Mr Goh and his daughter to do an initial assessment of their care needs, and to provide an avenue of support they can turn to, including appropriate types of assistance, education, or advice for managing their needs.

Dialogue and communication

Mr Goh and his daughter have stresses that they have not been able to share openly for one reason or another. One of them, or both, may have a strong desire for privacy and confidentiality. What sort of personalities do Mr Goh and Ying Ying have and what are their values? What are their individual strengths and what does ‘quality of life’ mean to each of them? Are all parties treated fairly? Is each person given due respect? Does each person have the ability and resources to care for the other’s well-being? For the trained community care practitioner, starting a sensitive conversation with this family is necessary for knowing what level of need or type of assistance they would find useful. The conversation, and any subsequent assistance, should not lead them to feel stigmatised.

Initial assessment

Assuming both Mr Goh and his daughter have agreed that they require assistance, a trained professional will then conduct an initial assessment non-intrusively in a skilful conversation with them together or individually, according to their preference. In this conversation, the care professional will pay attention to:

1. the physical health and functional status: any illness, visual or hearing impairment, nutritional status, incontinence, and conditions that may contribute to falling or difficulties with walking or moving;
2. the psychosocial status: any cognitive, behavioural and emotional issues, including signs of dementia, delirium, or depression;
3. access to caregivers: any present and potential caregivers, their willingness, competence and acceptability to the care recipient, signs of caregiver stress or good caregiver support;
4. cultural, social, or spiritual values: after rapport is built with Mr Goh and immediate needs are met/resolved, to explore his ideas about quality of life and end-of-life issues;
5. financial support: any need for financial support, and if so, whether Mr Goh is eligible for any insurance support (under a scheme like Eldershield, or IDAPE);
6. environment safety: in this case, assessing the food centre and, if the family permits, his home environment;
7. abuse risks: any physical, emotional, financial, psychological, neglect or self-neglect issues.

Care support planning

Following the initial assessment, the care professional will attempt to resolve any presenting problems by developing a care plan or recommending alternatives to Mr Goh and his daughter. It is important to offer alternatives and flexible recommendations when making care plans. The rationale for recommendations should always be explained, and the cost associated with each alternative clearly stated. The care professional is able to provide the necessary referrals when the family has agreed to a recommended care strategy.