Page 36 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHO OWNS THE CARE PLAN
articles often fail to reach the practicing physicians and other health care professionals in nursing homes. In fact, they often fail to reach medical directors who are not actively engaged in AMDA.
In Changing Perspectives on LTC Nutrition and Hydration, Steven Levenson, MD addresses several challenges of nutritional care for the elderly:
“...non-essential dietary restrictions should be loosened or removed, since very few individuals benefit from special diets or disease-specific supplements...This is especially important when there is continuing weight loss in the face of altered consistency or other restricted diets.”
“Management of all geriatric conditions involves some risks. No known evaluations or interventions can guarantee that someone will not aspirate. It is important to note that many elderly individuals with swallowing abnormalities and aspiration risk do not get aspiration pneumonia. In fact, there is evidence that altered consistency diets may increase the risk of nutrition and hydration deficits. Thickened liquids and pureed foods are often poorly tolerated. Tube feedings do not materially decrease the risk of aspiration.”
“Multidisciplinary team members, including health care practitioners, should be involved in balancing the risks of aspiration against the potential benefits of more liberal diets and food consistency, and deciding whether there are viable alternatives. There should be a discussion of the patient’s progress, goals, and objectives. Often, aspiration risks must be tolerated because of other, more immediate or probable risks such as nutrition or hydration deficits.” (Levenson, 2002)
In, The Facts about Dysphagia & Swallowing Studies, Levenson reports on a 1995 study published in the Journal of the American Geriatric Society by Groher et al., summarizing: “This study aimed to determine the appropriateness of dietary levels of residents with suspected feeding and/or swallowing disorders. Thirty-one percent of the residents in two facilities were prescribed a mechanically altered diet. Ninety-one percent were at dietary levels below that which they could tolerate safely; four percent were at dietary levels higher than they could tolerate; five percent were considered to be at the appropriate diet level.” The authors conclude that “many nursing home residents may be inappropriately placed or maintained on mechanically altered diets. Regular reevaluation of the dietary level is necessary because most may be able to eat safely at high levels.” (Levenson, 2003)
Specific to the issue of consistency modification as addressed in the 1995 study, standard practice in most facilities in 2009 still does not include regular reevaluation of dietary level, and may not include interdisciplinary care plan team (IDT) review of dietary level. And until the 2009 interpretive guidelines from CMS regarding quality of life specifically addressed the right of residents to refuse a consistency modification, some facilities so strongly enforced the professionally-ordered consistency modifications that they considered discharging residents who
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