Page 29 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHO OWNS THE CARE PLAN
there is so much more kitchen supervision needing to be done. One person cannot find the time to do justice to both kitchen supervision and making sure food stays safe, (while also) doing the in-depth care planning, assessing and evaluation for 95-100 year-olds who only want to live their last days in peace in a loving and caring environment with people who care. We can’t make them physically be 60 anymore, or fight Mother Nature in the overall aging process, but I feel that is what the regulations are asking us to do. (A Certified Dietary Manager response)
Challenge: Administration and health care professionals are held ultimately accountable in F280 for the resident’s care and safety, including clinical decisions, while also accountable in F151 and F242 for honoring resident rights and self-determination.
When speech therapy and a modified barium swallow show severe dysphagia, the resident diet is modified to a level one puree diet. The resident complies with the MD order for awhile, but is embarrassed to eat this food in the dining room and in spite of attempts to make the puree as presentable as possible, despite follow- up education by the SLP and RD and RN, the elder isolates herself in her room at meal times and social isolation and depression now become a part of her “problems” list and care planning for this becomes a focus. The elder soon develops weight loss and feels “ganged up on” each time she “complains” about the food that she does not want to eat and her rights are never a focus because our professional licensure is at risk if we do not uphold the MD order. If we do not offer more follow-up to progress the diet, we do not recognize the problem for what it is. Dysphagia is an ever increasingly recognized need in our institutionalized elders. Liability is in the forefront when there is a negative outcome. We fear to allow self-determination when liability is a threat. Our elders are captive and held to a different standard from what our communities expect. (Madalone, 2009)
It is company policy that all supplies come from one national company, and our ability to buy produce locally has been taken away from us. Hence menus are limited to what the national company supplies. All orders had to be sent in advance and although the cook consulted with the residents, their choice was limited. If a resident fancied a steak for his meal, he could have it the next week as it had to be ordered, so residents with memory impairment did not stand a chance of daily choice. We used to have fish and chips, an English tradition, but it is no longer available...economy versus resident choice is a hard nut to crack!!
We are fortunate to have a very supportive administrator willing to stand with our staff (in meeting) with surveyors, if need be, to support what we want to do. We all knew in the beginning that we would be doing things differently, (thereby) setting us up for deficiencies, but were determined not to let that detour us. We chose to work with the residents and families to determine how they wanted to live and then work within the regs to make it happen. I can’t think of a single regulation that we haven’t been able to meet within our households. We have found that as long as we have assessed the situation, discussed the risks and benefits with the residents, care planned the approaches, and followed the care plan, we have been able to do what the resident wants. (Oelfke, 2009)
Protecting our personal liability and professional standing places (the) most barriers against self-determination and participation, and (against) our stance as the “expert;” it is intimidating and coercive to our elders. Food is so often NOT dangerous, but too many CONTROLS for perceived health benefit or life extension does the opposite and impacts negatively on an elder’s quality of life. I
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