Autonomy and risky business
Jacqueline Vance, RNC, CDONA/LTC
Let's face it, nursing home culture change and honoring resident choice can still bring about an anxiety attack to the most laid back of nurses. Promoting resident autonomy without exposing providers to a risk of liability is kind of an oxymoron. But we've all heard it: “No risk, no reward.”
That doesn't mean someone won't still try to slap us with an F-tag or try to sue us, right?
However, we are here for the resident. We are not our resident's parents, and the days of us thinking “we know what is best” is as archaic as dinosaurs. The best interest of the resident is probably not the same in the resident's mind as it is in the staff's mind.
And sometimes perceived risk drives all common sense out the door. We can't try to eliminate risk by denying our residents their basic right of decision-making because we are risk averse. We have moved on (this is the 21st century) to individualizing care, collaborative decision-making and resident empowerment.
For example, I would ask you to look at the Rothschild Person-Centered Care Planning Task Force, A Process for Care Planning for Resident Choice (Feb. 2015) (prepared by M. Calkins, K. Schoeneman, J. Brush, & R. Mayer) – Hulda B. and Maurice L. Rothschild Foundation funded at http://ideasinstitute.org/.
This is a wonderful document that helps navigate the resident-centered care planning process that shows you how to honor the resident's choice and how to determine when a choice can't be honored. For example, a resident on oxygen feel sit is their right to smoke in bed. They say, “If I die, I die.” You say, you don't have the right to take the whole facility with you! But there are great ways to communicate choice through the care plan and monitor (and possibly revise) that choice through the care plan (except for that smoking in bed thing!)
The most important things to mitigate risk are these: First have a cognitive evaluation done. You need to validate if the resident has the decision-making capacity to functionally make a choice. Then if so, answer these questions (AND document!!!):
1. Can they express a choice clearly?
2. Can they give you reasons why the want this choice?
3. Are the reasons rationally related to the facts?
4. Can they appreciate the personal consequences of the choice made?
If the answer is yes to all of these questions, ask your doctor or pharmacist about decisionEX … (OK, just kidding.) But, yeah, if the answer is yes to all of these, and their decision won't harm others, we have to take the risk.
Examples of what this might involve include alcohol use in combination with medications they are on; dietary choices that may pose choking hazards; ambulating without the use of a recommended aide such as a walker; not taking prescribed blood pressure medications, etc.
This is the resident's decision, not ours.
We work in long-term care. We are never going to totally avoid risk. Risk is in the nature of our business. But we can put a realistic perspective on it and manage it.
Did you know that the implementation of culture change is actually associated with fewer health-related and quality of life-related deficiencies? (SC Miller et al., “Does the Introduction of Nursing Home Culture Change Practices Improve Quality?”, J. AM. GERIATR. SOC'Y 2014;62(9):1675-1682)
So let's do what is right. Just be sure to document your conversations and let the older adults be adults. By the time the boomers get to our facilities, we'll be ready for the demands and individualism of that silver tsunami! (Except for the smoking weed in bed!)
Just keeping it real,
The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, an APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.