Page 33 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHO OWNS THE CARE PLAN
MEETING THE CHALLENGE OF RESIDENT SELF-DETERMINATION
While the pathway to modifying care planning to support individualized care is well described, the path to facilitating resident self-determination is not as clear. How do we define “normal” and “meaningful” for each resident? How do we assure that residents are supported in defining their personal choices, particularly residents with the increased complexity of the presence of cognitive loss? While this work has been the subject of much research for over 20 years, absence of an accepted best practice approach leaves much opportunity for less-than-optimal approaches for many of our elders, and confusion among health professionals regarding outcomes and regulatory compliance.
This challenge is not new. Several distinguished researchers have devoted their careers to addressing it. In 1991, Rosalie Kane co-authored Values & Ethics for a Caring Staff in Nursing Homes: A Training Guide. It guided the transformation of the care planning process and resident decision making at Bigfork Valley Communities. Developed with the hope of assisting those struggling with the implementation of OBRA ‘87, “It was derived from a research project funded by the Retirement Research Foundation that examined personal autonomy in the everyday life of nursing home residents and the way nursing assistants can contribute to appropriate autonomy, dignity, privacy, sense of control and general well-being for the residents under their care.” (Kane, 1991) Yet most facilities still struggle with these issues daily.
Far too few residents can easily express their true choice. Some, on admission, are so affected
by the losses of transitioning from their community home, that simple pleasures and personal choices in matters of daily living seem insignificant. Many, after living in the traditional nursing home environment for just a few months, come to believe that “normal” is the institutional way. Others, when presented with options, endorse the expressed or perceived opinions of their caregivers out of fear of reprisal or concern for their caregivers. Vocal residents may claim spokesperson rights for their more quiet peers. Realistically, why would a resident want to eat
every meal off a drab grey tray? Why would they want to wear a pink and blue stripped terry
cloth bib at every meal? Why would they want to get up before the sun if they were a person
who preferred to sleep in prior to moving in? Are they answering from true personal choice or from institutionalization or concern for staff convenience? But going back to the simple questions ... What does the resident want? How did they do it at home? How can we do it here? ... is almost always a reasonable approach.
Consider the “terry cloth bib” debate as one simple example. Some argue residents want the pink and blue stripped bibs because they don’t want soiled clothes, or because our laundry services don’t get the stains out so clothes are ruined from spills, or because napkins don’t work as well. Consider what did they do at home? Perhaps an apron, or even a smock; at a restaurant perhaps a lobster bib or a spaghetti bib? If they spilled spaghetti on a favorite blouse, did they use Shout, or soak it so the stain did not set before washing, or run a small washer load right away? So what could we do to give our elders better options than the traditional terry bib?
We could provide other options that work just as well, we could change the way we handle
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