Page 24 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHO OWNS THE CARE PLAN
THE RIGHT AND DIGNITY OF CHOICE AND RISK
Inevitably in many cases someone involved will begin to raise questions about risks or potential harm to a resident, even when a resident makes a choice. Sometimes this is because the person raising the question (provider, family member, surveyor, advocate, ombudsman) believes the resident’s choice will lead to harm. Raising questions is sometimes necessary and helpful. But it can become complicated and the final decisions rarely offer certainty.
The idea is not new to long-term care. In 1976, eleven years before OBRA ’87 emphasized the issue, Langer and Rodin published results of a field experiment on a group of nursing home residents in which they demonstrated that the experimental group (the group with objective control) showed a significant improvement over the control group in alertness, active participation and general sense of well-being. Specifically related to food, they noted: “Should an elderly diabetic be allowed to have ice cream? The relationship between diabetes and sugar is probabilistic even though it is treated by many people as absolute. Whether or not that ice cream will hurt the person depends on what else was eaten that day, how much ice cream is consumed, whether or not the person has exercised, and so on. Recent evidence, in fact, suggests that no sugar is more dangerous than a small amount of sugar. Regardless of the finding, I think nursing home staff should make recommendations, but leave the final decision up to the resident. One cannot know today what ‘facts’ will turn up tomorrow.” (Langer and Rodin, 1976)
Does it not logically follow that lack of choice can harm a resident’s general sense of well- being?
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483.15(b) – Self-Determination and Participation The resident has the right to—
(1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care:
(2) Interact with members of the community both inside and outside the facility; and
(3) Make choices about aspects of his or her life in the facility that are significant
to the resident.
In their recent study, Depression in Older Nursing Home Residents, Choi, Ransom and Wyllie acknowledge, “More effective approaches are likely to be the ones that not only incorporate the residents’ choices and preferences to the greatest extent possible, but also encompass the changes in nursing homes’ institutional environments and culture.” (Choi, Ransom and Wyllie, 2008)
Not long ago we admitted a woman who brought her iron and ironing board with her – her simple pleasure. She was admitted with dementia and even as long as we have been working in the households, staff questioned whether she could safely iron. They worked with her to develop a schedule for 1:1 visits giving her time to iron while supervised. Guess what happened – it didn’t take long until she stopped ironing. She didn’t want to take up the staff time so that she could continue to iron. The team came back together and talked about what is the worse thing that could happen. They decided together that it was more important
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