Page 70 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
Appendix A
APPENDIX A
Improving the Quality of Care in Nursing Homes. Institute of Medicine. Committee on Nursing Home Regulations. National Academy Press: Washington, D.C. 1986. Selected excerpts:
The attributes of quality in nursing homes are very different from those in acute medical care settings such as hospitals. The differences stem from the 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.
Nursing home care is both a treatment and a living situation. It encompasses both the health care and social support services provided to individuals with chronic conditions or disabilities and the environment in which they live. Nursing homes are “total institutions” in which care-givers, particularly nurses/s aides represent a large part of the social world of nursing home residents and control their daily schedules and activities. This is the total environment for many nursing home residents for the duration of their stay, which may be several years. As a result, deficiencies in medical or nursing care or in housekeeping or dietary services, which could be tolerated during a brief hospital stay, become intolerable and harmful to well-being when they are part of an individual’s day-to-day life over a longer period.
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.
Many aspects of nursing home life that affect a resident’s perceptions of quality of life – and therefore sense of well-being – are intimately intertwined with quality of care.
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
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