Page 34 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHO OWNS THE CARE PLAN
soiled clothes, we could perhaps even change the way we assist the resident in dining to
avoid the stain from occurring. If an elder moved in with a terry cloth bib (which they don't, because people don't wear bibs in society), it would be appropriate to continue to use it. But, if we institutionalized them to wear it, we need to return to the question: what did they do at home?
Similarly, consider the “institutional tray” debate. Some argue that residents want the tray to be sure they get their own food, or that families want them to be sure they get the food they need, or that they need the tray to define their personal eating space, or that they need the tray to keep others at the table from snatching their food, or that they don’t want to make extra work for staff taking the food off the tray. How sad. Unless a resident always ate on a tray from a far-away kitchen before they came, we need to address their concerns, resolve them by changing our meal service, and honor their historical way of dining. The fundamental reason to eliminate the institutional tray is not so much the appearance of the tray as it is the limitation of true choice when meals are served from a remote kitchen with no point of service choice. Yes, the tray is institutional in appearance, but much more than that, it is institutional in restriction of true choice, just like in prison, in school (before cluster kiosks) and in the hospital (before room service). Like these service sectors, we need to change our service now.
The greater challenges of self-determination for residents with limited decision-making capacity have been successfully addressed by others, as in the United Kingdom’s Mental Capacity Act 2005 Code of Practice that provides guidance to “those who have a duty of care to someone who lacks the capacity to agree to the care that is being provided.” (Department for Constitutional Affairs, 2007) The recent Nufield Council on Bioethics publication, Dementia: Ethical Issues, provides a comprehensive review and extensive references and resources. (Nufield Council on Bioethics, 2009) Why do so many of our peers resist the premise of resident choice for our elders with limited decision making capability? We must learn from those working in developmental disabilities and mental health, here and abroad, and apply their best practices in our daily work.
Resources abound in the United States and Europe from academia, state Quality Improvement Organizations, professional care-giving peers in developmental disabilities and mental health, advocacy organizations and others. But translating resources into practice is a challenge for all involved. We need an individualized care practice guideline specific to long-term care that could be incorporated into regulatory overview, interpretive guidance, protocol and investigative procedures. Such a document could guide us all on a pre-determined path to excellence in honoring self- determination both for residents with full and limited mental capacity. Hopefully, a national workgroup with representatives from all stakeholders and peer organizations will carry out the sacred work of developing individualized care practice guidelines that will then be universally incorporated to serve our elders' right to self-determination.
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