Long Term Care Administration

Week 10 – November 11, 2010

Empowerment, Autonomy,

Ethics, & Law

Legislative Context

With regionalization, governments rely much more heavily on legislation & regulations to accomplish the goals they want to achieve.

Governments must conform with the Canadian Charter of Rights and Freedoms, Canadian Constitution.

Chapter 15 of the Charter, governments cannot discriminate on such grounds as ethinic background, national origin, age, sexual orientation, or physical or mental disability when formulating policies, whether these policies are adopted by legislation or not.

Legislative Context

Chapter 15 of the Charter allows for certain facilities to give preference to individuals from a particular ethnic background or age group, as long as placement in a similar facility within the same general geographic area will be possible as an alternative.

German, SUCCESS, Louis Brier, Icelandic, Finnish, Kopernick Lodge,

Specific Rights in Facilities

Common Law, Regulation, Legislation, Funding Contracts determine rights of residents in LTC Facilities and clients in home support agencies.

Caregivers should ensure that residents have certain rights related to privacy and autonomy.

These rights should be jealously safeguarded and subject only to such reasonable limitations as arise out of living in an environment together with other individuals.

Privacy and Autonomy

Residents should have the greatest control over their rooms.

Staff should ask permission to enter.Should be allowed the choice of

uninterrupted sleep and without bed checks would not be assisted in a life threatening situation.

Residents who are capable of unlocking their door, should be able to lock it.

Privacy and Autonomy

Balance right to privacy and autonomy with the rights of others to be free from risk and nuisance.

Right to smoke balanced with the right of others to be free from smoke.

Television viewing not a choice, it’s a right.Alcohol usage acceptable within limits.

Medication

Only medication administered by a MD can be provided to residents.

Medication Safety Advisory Committee – interdisciplinary committee that reviews medications and consults on the continuation of the medication.

Protection of seniors in LTC facilities from non-prescribed medication.

Use of Restraints

Adult Care RegulationsDefinition of restraintsWhen they may be appliedReassessmentsMonitoring and DocumentationMay only be used in an emergency or

when it preserves life or prevents serious harm to the person or to others

Placement

Admission of persons with Alzheimer’s Disease who need facility care in a closed unit but are incapable of giving consent.

Advance Directives allow for people to make plans in the future if they become decisional incapable.

Guardianship and Committee

Right to Sexual Expression

It is the resident’s legal and morale right to have their wishes complied with.

The views of the staff or other residents as to what sexual relationships, should be allowed within the facility has absolutely no bearing on the matter.

Right to dignity and individuality.

Abuse and Neglect of Residents

Physical, sexual, financial abuse and neglect must be reported.

Abuse is a criminal offence.Facility is liable for incidence that occur.Due diligence to reduce risk exposure.To reduce liability some agencies ensure

that individuals are being cared for by same sex formal caregivers.

Right to Long Term Residency

Right to die in a care facility where the individual has lived for many years.

Any transfer should be handled with great sensitivity,

Spouses when one needs to be transferred and the other does not require higher levels of care.

The only answer is the need for more multilevel facilities.

Transfer and Discharge

No facility shall transfer a resident without their consent.

Formal process exist to determine if the resident’s needs can continue to be met.

Notice must be given to the resident.Before discharge, the resident must be

assisted by identifying alternate arrangements or community resources.

Consent to Health Care

Right to consent to as well as to refuse any care and services offered.

Informed consent must first be obtained before any treatment can take place.

Common law, legislation allows for obtained consent in advance directives.

Proxy and instructional advance directives.

Physicians and Written Treatment Orders

MDs have refused to sign orders indicating that no resuscitation should be attempted, or any other aggressive treatment or transfer to acute care.

Disconnect between individual’s wish and the MD’s own moral and religious views.

DNR orders – futile treatment.

Confidentiality

No information should be released to anyone unless the resident has consented.

Individuals may access their medical information except where there is a significant likelihood of a substantial adverse effect on the physical, mental or emotional health of the individuals or harm to a third party.

Rights of Long Term Care Facility Staff

Violence in the Workplace.WorkSafe BC has targeted this area as a

focus to reduce risk to injury in LTC.Zero Tolerance – not acceptable.Too many staff members have been

assaulted or insulted and told to put up with this because it goes with the territory.

Relationships with Other Health Care Professionals

Chiropractors, podiatrists, massage therapists, and other health care professionals have the right to provide treatment or care in the facility.

MDs must abide by rules and regulations of the facility such as documented a visit.

Medical coordinators work with MDs to ensure consistent medical practice.

Home Care and Support Issues

Advance directives are more difficult to exercise in an individual’s home.

Home care workers are more at risk in someone else’s home.

Workers are subject to discrimination by clients, even if they are disabled.

Financial abuse accusations are more common in home support.

Mental Incapacity

Adult GuardianshipTo obtain substitute consent to provide major or

minor health care to an adult, a health care provider must choose the first, in listed order, of the following who is available and qualifies:

the adult's spouse; the adult's child; the adult's parent; the adult's brother or sister; anyone else related by birth or adoption to the

adult.

Mental Incapacity

Adult GuardianshipTo qualify to give, refuse or revoke substitute

consent to health care for an adult, a person must

be at least 19 years of age, have been in contact with the adult during the

preceding 12 months, have no dispute with the adult, be capable of giving, refusing or revoking

substitute consent, and be willing to comply with the duties in section 19.

Empowerment to Meaningful Autonomy

Balancing respect for the autonomy of residents with the duties to protection and care, especially for those with diminishing autonomy.

Societal and family responsibilities to the elderly and the care dependent.

Limits of caregiving obligations of both family and professional care providers.

Empowerment to Meaningful Autonomy

Balancing privacy and the rights of individuals with safety and duties to others

Responsible management of limited resources

Promotion of truly meaningful autonomy

Context of Long Term Care

Diverse set of goals, care recipients, care providers and various forms and levels of care.

Primary goal is to enable residents to have as meaningful a life as possible, for as long as possible, given their interests, abilities and impairments.

Goals could include rehabilitation and functional improvements.

The Context of Long Term Care

Increasing number of younger persons also receive long term care with physically disabled adults with conditions such as:

Multiple SclerosisSpinal cord and head injuriesLate stage cancer and HIV-AIDSTechnology dependent disabled childrenDevelopmental delayed – cerebral palsy

Meaningful Autonomy

Self governance or self ruleDeciding what to have for lunch and higher

stake decisions like whether to use a feeding tube to prolong one’s life.

Allows people to live purposefully and meaningfully, responding to their own goal, values, wishes and plans in ways that they perceive as giving their lives purpose and meaning.

Meaningful Autonomy

Two StrategiesRecognition affirmed in resident centred

mission and values statements, put into practice through strategic plans and policies.

Creating opportunities for choice and providing resources for learning, can help to empower people to achieve autonomy.

Challenges for Meaningful Autonomy

1. Becoming Committed to promoting, sustaining and not frustrating meaningful autonomy.

2. Viewing patients as more than dependent.

3. Moving beyond a focus on advance directives and advance care planning.

4. Achieving meaningful autonomy despite cognitive impairments.

Challenges for Meaningful Autonomy

5. Achieving meaningful autonomy in light of significant life long disability.

Challenges for Meaningful Autonomy

1. Becoming Committed to promoting, sustaining and not frustrating meaningful autonomy.

Learn how the interests and well being are understood and desired by the recipients of care.

Participation in health care decision making may facilitate good care.

Challenges for Meaningful Autonomy

2. Viewing Patients as more than DependentDependence and independence are not

absolute.One can only be independent within a set

of constraints – one’s body, relationsjip and the world.

To eat people are dependent on others…

Challenges for Meaningful Autonomy

3. Moving Beyond Advance Directives to Advance Care Planning

Surrogate decision makers (SDM).SDM makes decisions in accordance with

the known wishes or choices made by the resident when capable.

Instructional directives and proxy directives.

Challenges for Meaningful Autonomy

4/5. Cognitive Impairments & DisabilitiesEmpowerment needs to emphasize the

psychological and spiritual aspects of autonomy in face of the obvious limitations in physical autonomy.

Care providers should be acutely aware that these young and middle aged adults are writing their life history with limitations.

Making It Happen

Role in respecting residents’ autonomy in long term care.

Role in offering and supporting choices beyond those occasions when written consent is required.

Maintenance of personal integrity enables relationships that matter and support personal and spiritual values.

Making It Happen

Role in accepting and honouring choices and self understanding.

Role of facilities which have the power to severely constrain residents’ autonomy.

Role in providing guidance to care providers and resident when the law and professional codes are silent.

Physical environment should foster achievement of autonomy.

Making It Happen

Role as educating the delivers of long term care of the importance of autonomy.

Role of policies and procedures to create and protect organizational climate that fosters autonomy.

Eliminate anti-autonomy polices.