Image of Joseph E. Ibrahim, M.B.B.S., Ph.D.

Drinking alcohol is a valued pastime for some long-term care residents, but purposeful policies can keep the practice from becoming a moral, logistical and legal quagmire for facility operators, according to a new article by forensic medicine experts.

Tensions often arise between the older person’s right to autonomy and their own health and safety, the authors contend. Managing these tensions requires clarity about the role of the nursing home, explains Joseph E. Ibrahim, Ph.D., head of the health law and aging research unit at Monash University, in Australia, and an expert in healthcare quality and safety . 

“Is their responsibility to provide an authentic home environment ever outweighed by the responsibility to preserve the health and safety of the older person who has voluntarily made a decision that is potentially harmful to themselves?” he and his colleagues ask.

To answer that question, LTC operators should consider three key factors when making decisions: public health, human rights and legal interests, the authors stated. In the absence of clear policy, one framework likely will be emphasized over another. Clinicians are more likely to favor a public health approach, for example, whereas administrators are more likely to favor a legal approach, leaving human rights considerations unaddressed. The best policy will balance all three, the authors argue.

The authors give examples of touchy situations involving alcohol that some facility caregivers may recognize, such as: A resident with a disabling stroke who needs mealtime assistance asks staff members to help him ingest home-brewed spirits made with unknown ingredients, or a resident with Parkinson’s disease respects no-alcohol rules on facility premises but regularly returns inebriated from day trips, resulting in falls or adverse behaviors.

Implementing a policy of total prohibition is unrealistic and difficult to enforce, note Ibrahim and colleagues. But allowing for unlimited alcohol consumption also is inappropriate for safety reasons. A nuanced approach that balances the older person’s autonomy and right to exercise choice with the safety of other residents and nursing home staff is ideal, they say. 

The authors propose detailed suggestions within each of the three decision-making frameworks, including:

Public health: Consider the person’s individual risks and benefits associated with alcohol consumption, whether the older person has the capacity to make the decision, and whether it is appropriate for the facility to supply alcohol.

Legal factors: Stress awareness of legislation outlining residents’ rights, the possibility of liability in negligence, the law surrounding decision-making capacity, and liquor licensing that governs the supply of alcohol in these settings. 

Human rights: Remain aware of the social and psychological harm experienced by an older person when something important or pleasurable is removed, including social isolation, loss of culture and frustration at loss of control over decision-making. Instead of viewing an older person as “vulnerable” with “risks and harm” to be managed, a human rights framework will be collaborative, taking a resident’s input into consideration. This framework may establish a context for the personal choice that is crucial to the risk management process.

“Establishing inclusive and thorough decision-making processes is key to achieving better consumer-directed care,” the authors concluded.

The full study was published in the journal JAMDA.