Long Term Care Administration

1
Long Term Care Administration

• Week 10 November 11, 2010
• Empowerment, Autonomy,
• Ethics, Law

2
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.

3
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,

4
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.

5
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.

6
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, its a right.
• Alcohol usage acceptable within limits.

7
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.

8
Use of Restraints

• Adult Care Regulations
• Definition of restraints
• When they may be applied
• Reassessments
• Monitoring and Documentation
• May only be used in an emergency or when it
  preserves life or prevents serious harm to the
  person or to others

9
Placement

• Admission of persons with Alzheimers 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

10
Right to Sexual Expression

• It is the residents 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.

11
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.

12
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.

13
Transfer and Discharge

• No facility shall transfer a resident without
  their consent.
• Formal process exist to determine if the
  residents 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.

14
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.

15
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 individuals wish and the MDs
  own moral and religious views.
• DNR orders futile treatment.

16
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.

17
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.

18
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.

19
Home Care and Support Issues

• Advance directives are more difficult to exercise
  in an individuals home.
• Home care workers are more at risk in someone
  elses home.
• Workers are subject to discrimination by clients,
  even if they are disabled.
• Financial abuse accusations are more common in
  home support.

20
Mental Incapacity

• Adult Guardianship
• To 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.

21
Mental Incapacity

• Adult Guardianship
• To 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.

22
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.

23
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

24
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.

25
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 Sclerosis
• Spinal cord and head injuries
• Late stage cancer and HIV-AIDS
• Technology dependent disabled children
• Developmental delayed cerebral palsy

26
Meaningful Autonomy

• Self governance or self rule
• Deciding what to have for lunch and higher stake
  decisions like whether to use a feeding tube to
  prolong ones 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.

27
Meaningful Autonomy

• Two Strategies
• Recognition 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.

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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.

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Challenges for Meaningful Autonomy

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

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Challenges for Meaningful Autonomy

• 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.

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Challenges for Meaningful Autonomy

• 2. Viewing Patients as more than Dependent
• Dependence and independence are not absolute.
• One can only be independent within a set of
  constraints ones body, relationsjip and the
  world.
• To eat people are dependent on others

32
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.

33
Challenges for Meaningful Autonomy

• 4/5. Cognitive Impairments Disabilities
• Empowerment 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.

34
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.

35
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.

36
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.