Page 23 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHO OWNS THE CARE PLAN
483.10 Resident Rights
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights...
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483.10(a) Exercise of Rights
483.10 (a)(1) The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
483.10 (a)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.
Interpretive Guidelines 483.10 (a)(1)
Exercising rights means that residents have autonomy and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the
facility’s rules, as long as those rules do not violate a regulatory requirement.
In Reassessing Autonomy in Long-Term Care, George Agich acknowledges the paradoxical realities of long-term care when viewed from the perspective of autonomy. Pat Maben, retired pioneering reformer of the regulatory environment in Kansas, says this article changed her life by having a profound effect on her, first as a DON, and ultimately forcing her to look at her role as a regulator and what she should promote in Kansas. With the full support of the Secretaries of Health, by 1995 the ideas of Agich and others were influencing resident-directed care and nursing home design in that pioneering state.
Agich asserts that in moral life, a fuller conception of autonomy than the common abstract liberal concept is required – one that “acknowledges the essential social nature of human development and recognizes dependence as a non-accidental feature of the human condition. Such a concept would systematically attend to the history and development of persons and take the experiences of daily living into account; it would view individuals concretely and see choice as a problem of positively providing options that are meaningful for concrete individuals, rather than as an issue of removing obstacles to choice or impediments to action.” (Agich, 1990)
Agich further develops the concept in Dependence and Autonomy in Old Age, with the goal of developing “a framework for rethinking and reconsidering the everyday ethics of long-term care. I accept that ethical conflict, dilemma and tragedy are inescapable features of this setting...I strongly believe that well-motivated caregivers can improve their practices if they could be provided with a useful way to think about respecting the autonomy of persons needing long-term care...I have the confidence that those who are situated closer to the phenomena of old age and disability are better able to devise solutions to problems or to make improvements in programs than someone trained in bioethics and philosophy.” (Agich, 2003)
Development and implementation of best practice tools to achieve that end could bring the right of self-determination to most, if not all, long-term care residents.
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