Page 38 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHO OWNS THE CARE PLAN
“Resident Involvement in Meal Planning: The Registered Dietitian should collaborate with other health professions and administrators to encourage older adults’ involvement in planning menus and meal patterns since studies show that this may result in improved food and fluid intake.”
“Collaboration for Modified Texture Diets: The Registered Dietitian should collaborate with the speech-language pathologist and other healthcare professionals to ensure that older adults with dysphagia receive appropriate and individualized modified texture diets. Older adults consuming modified texture diets report an increased need for assistance with eating, dissatisfaction with foods, and decreased enjoyment of eating, resulting in reduced food intake and weight loss.”
“Contraindications for Enteral Nutrition: Enteral nutrition may not be appropriate for terminally ill older adults with advanced disease states, such as terminal dementia, and should be in accordance with advance directives. The development of clinical and ethical criteria for the nutrition and hydration of persons through the life span should be established by members of the health care team, including the Registered Dietitian.”
Unfortunately, these evidenced based guidelines are not yet widely accepted as standards of practice, and even more unfortunately, standards of traditional best practice developed for individuals at earlier stages of the life cycle are currently applied to elders, often limiting their choices, limiting their quality of life, while well-meaning practitioners practice a medical model of care. Madalone sums it up well: “Life extension with medically advanced treatments or imposed chronic condition management at an advanced age negating choice or satisfaction often leads to negative outcomes that are then managed with more liberal approaches that should have been the approach from the beginning.” (Madalone, 2009)
From an admittedly elementary, superficial and incomplete review of only three current issues in nutritional care of the elderly (therapeutic diets, consistency modified diets, end-of-life care), it is evident to this practitioner that development of appropriate professional standards of practice is beyond the scope of individual provider practice. Yet, such standards are essential to assure quality of care and quality of life in nutritional care in these and other unspecified issues of nutritional concern for elders in long-term care. The consistency of observations of improvements in both quality of care and quality of life for residents living in transformed pioneering facilities that adopt the professional recommendations quoted herein cannot be merely coincidental, and with proper professional focus, may be codified into professional standards of practice.
As an industry, we have successfully faced the painfully difficult challenges of restraint reduction and gifted our residents their right to mobility and freedom of movement. Joshua Weiner et al. reviewed progress in quality assurance in the 20 years after the passage of OBRA 87, citing the decline of restraints and a decline in the organizational culture that supported their use from 38% prior to OBRA 87, to 28% following the implementation of OBRA 87, to less than 6% (of long-stay nursing home residents had been restrained during the last 7 days) in 2007. (Weiner, 2007)
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