Page 61 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHAT MAKES NEW IDEAS DIFFICULT?
Clinical nutrition, medical nutrition therapy and the role of nutrition in the management of acute and chronic disease appear to be the primary focuses of the RD and DTR. Food service management and sanitation appear to be secondary focuses for the RD, and often the primary focus of the CDM. If these are consistently the focuses of professional education, of professional self-development, of standards of practice...who, then, is the primary advocate for resident rights and self-determination?
Our practice needs to focus on the science of wellness in elder care from a psychosocial aspect. What resident rights really address are rights to all choices, good and bad. We need to focus on quality of life from all angles, and redefine wellness or wellbeing as dining with control and choices, community, friends socializing, dignity and respect. (Madalone, 2009)
Well-Being: Beyond Quality of Life...The Metamorphosis of Eldercare provides such focus and definition. Calling for a metamorphosis of long-term care, the authors define “the ultimate outcome of the person-directed model as ‘WELL-BEING’” and the Domains of Well-Being as identity, growth, autonomy, security, connectedness, meaning, and joy. (Fox et al, 2006) What a world away from weight, albumin, BMI, RDI, BUN, HgA1C, Stage IV, mg, mEq, gm, kcal and all the traditional measures of successful nutrition intervention. Dietitians are called to advocate aggressively and work tirelessly for residents to champion their nutritional well-being in all domains.
The realities of scarce resources present a challenge to dietetic practitioner in long-term care. Time is money, and recent revisions in the interpretive guidelines, as well as recent affirmation of the RD role in clinical assessment and the CDM role in production management, leaves many RDs seeking additional hours to complete his/her job. Who, then, is the primary advocate for resident rights and self-determination? Who has the opportunity to build the relationships foundational to resident-directed care? Who has the opportunity to know each resident well, their preferences, stated or silent? To know their goals, consistent with medical recommendations or not? Who has the opportunity to continually support resident right to refuse treatments, while also offering ongoing opportunities to comply? The clinical focus of RDs and DTRs in long-term care leaves little time for chatting over a cup of tea, for observing the service in multiple decentralized dining rooms, indeed for just getting to know the resident as a person...could this be the CDM role, replacing the time historically delegated to nutrition assessment activities? Certainly, the team of nutrition professionals must accept this priority, and while each team may designate primary accountability differently, the full team must be held accountable for the professional advocacy for resident rights and quality of life in dining.
A Challenge to Accountability to All Professionals
Shields offers a challenge of accountability to all professionals, sharing his thoughts on the
biggest barriers to advancement of a good life for our residents –
After years of observation, I am convinced that the people with the power remain the biggest barrier to meaningful culture change in long-term care. They are too easily satisfied. Even as they gravitate toward this new way, their old way of thinking is so strong it keeps leaders from truly changing the organization and empowering teams. The
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