Page 5 - The Deep Seated Issue of Choice

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THE DEEP SEATED ISSUE OF CHOICE
WHERE DO WE START?
characteristics of the residents of nursing homes, their care needs, the circumstances and settings in which the care is provided, the expected outcomes, and the fact that for many residents, the nursing home is their home, not merely a temporary abode in which they are being treated for a medical problem. Thus, quality of life is very important for its own sake (that is, as an outcome goal) and because it is intimately related to quality of care in nursing homes.
The physical, psychosocial, and environmental circumstances and outcome expectations of nursing home residents distinguish the goals of nursing home care from those of acute medical care. In acute care, treatment goals are based on medical diagnosis. In nursing homes, the care goals are based on physical and psychosocial assessment. They focus on restoration, maintenance or slowing of the loss of function, and on alleviation of discomfort and pain.
In sum, long-term care is directed primarily at relieving conditions that result from chronic physical or mental disorders or the chronic after-effects of acute disorders. Equally important is relief of pain and discomfort.
Conflicts of values and ethics are inherent in nursing home care – for example, conflicts between care requirements, as judged by professions, and the rights and preferences of the resident. Should a very old, perhaps mildly demented resident, who is not legally incompetent and who declines to eat, be fed by naso-gastric tube even if he strongly objects to it? What about residents who decline to take medication or other treatments prescribed to manage their chronic disease? Should dietary preferences of a resident override adherence to a medically prescribed dietary regime? Should a frail, unsteady resident with osteoporosis, who insists on walking by herself, be permitted to walk around unescorted even though there is a substantial risk that she will fall and suffer a hip fracture?
...residents who receive good personalized care and opportunities for choice have higher morale, greater life satisfaction, and better adjustment.
Twenty-three years later, we come together to consider many of the fundamental questions detailed in the IOM report on the deep seated issue of choice, specifically: what is possible, who owns the care plan, how do we effect the deep organizational change needed so that a person’s right to choice in their own home is honored, what makes these new ideas so difficult. Twenty- three years later, far too many of our elders are still waiting for meaningful choice.
THE CHALLENGE OF QUALITY NUTRITIONAL CARE
The epidemic of malnutrition, dehydration and weight loss in our long-term care institutions is well documented, well known to all and the subject of in-depth medical focus, legislative inquiry and legal investigation. Landmark research in 2000 by Burger, Kayser-Jones and Bell, Malnutrition and Dehydration in Nursing Homes: Key issues in Prevention and Treatment, supported by the Commonwealth Fund, found:
Four issues are key to the prevention and treatment of malnutrition and dehydration: inadequate staffing, poor environment, insufficient data collection and lack of enforcement. Finding solutions that address these issues will require
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