Page 57 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHAT MAKES NEW IDEAS DIFFICULT?
Recommendation: National workgroup develop guidelines for living wills and advanced directives that clearly address the issues of nutritional care outlined in individualized care practice guidelines to clarify the resident’s choice on key decisions in both disease
management and end of life care.
Recommendation: National interdisciplinary work group address individualized care
practice in the care planning process as it relates to resident directed care.
OBRA ‘87 SUPPORTS CULTURE CHANGE – LACK OF CLARITY ON PROFESSIONAL STANDARDS AND ACCOUNTABILITY OFTEN IMPEDE IT
The rights of our residents seem clear, but the accountability for ensuring their rights is not as clear. The competing challenges discussed previously in the context of care planning illustrate the complexity of advocating for resident rights. In the final analysis, we all are accountable, both professionally and personally, for honoring the rights of our residents to self-determination and quality of life, in addition to providing quality clinical care. But as a practical matter in the day-to-day complexity of competing challenges, just who is ultimately accountable for self- determination and quality of life in nutritional care? The medical director, physician, administrator, director of nursing, social worker, speech therapist, dietitian... just who? Each profession must embrace the challenge and evolve as leaders in resident-directed care.
Medical Accountability Is Receiving New Emphasis
For over 30 years, Medicare regulations have required medical directors to implement resident care policies and coordinate medical care in skilled nursing facilities. Improving the Quality of Long-Term Care, a 2001 Institute of Medicine Report, found their authority and accountability unclear, one factor leading to the 2003 AMDA revision of Roles and Responsibilities of the Medical Director in the Nursing Home and the Role of the Attending Physician in the Nursing Home. In Patient Care-Clinical Leadership, the medical director is to “help review policies and procedures regarding the adequate protection of patients’ rights, advance care planning, and other ethical issues.” In Provide Appropriate Care to Patients, “The attending physician should: in consultation with the facility staff, manage and document ethics issues consistent with relevant laws and regulations and with patients’ wishes, including advising patients and families about formulating advance directives or other care instructions and helping identify individuals for whom aggressive medical interventions may not be indicated.” (Wilson, 2005)
These documents and AMDA’s position statements are consistent with the recently revised CMS guidelines regarding the medical director, and should assist in clarifying the authority and accountability of the role as suggested by the IOM report.
Reviewing the revised federal guidelines, Jeffrey Levine notes that, in addition to the barrier of maintaining appropriate reimbursement for the medical director, “another barrier to regulatory compliance is lack of physician training in such critical spheres as geriatric medicine, team dynamics, the regulatory process, and leadership skills. Lack of proper training in geriatrics is
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