HEALTH CARE DECISION–MAKING IN THE NURSING HOME

1. HEALTH CARE DECISION–MAKING IN THE NURSINGHOME ltcpractice.com

2. Every nursing home resident should be given the opportunity to make decisions about his/her health care until they can no longer make such decisions. ltcpractice.com

3. The ability to make health care decisions, or decision-making capacity (DMC), is determined by the physician after interviewing and examining the resident. ltcpractice.com

4. The determination of DMC is based on the resident’s ability to: • Understand and communicate their preferences • Understand the risks and benefits of treatment options • Relate care decisions to their values and circumstances • Give a reason for their decisions ltcpractice.com

5. When the resident is without DMC who will make the decisions? If the resident does not have the capacity to make health care decisions the physician will consult with the health care agent or other legal representative. ltcpractice.com

6. Who is the health care agent or legal representative? The health care agent has previously been appointed by the resident and the agent’s name is recorded on a “Health Care Proxy” form. The legal representative is named in a “Living Will” or other legal document. ltcpractice.com

7. How will the physician know whom to contact? The Health Care Proxy or Living Will should be presented to the social worker at the time of admission to the nursing home. A copy of the form(s) will be kept in the resident’s chart for the physician to review. ltcpractice.com

8. What health care decisions will be discussed? • The Do Not Resuscitate (DNR) order • Overall plan of care: aggressive or conservative • Nutritional supports: intravenous, tube feedings, oral only • End of life issues: hospitalization or comfort care ltcpractice.com

9. What is a DNR order? The Do Not Resuscitate (DNR) order instructs the nursing home staff and emergency personnel not to perform cardiopulmonary resuscitation (CPR) on a resident whose heart has stopped beating and who is not breathing. Discussion of the DNR order is germane to all other health care decisions. ltcpractice.com

10. Is there more to consider with the DNR order? The DNR order DOES NOT restrict emergency personnel from intubating (inserting a tube into the throat to maintain an airway) to perform cardiopulmonary resuscitation (CPR) on a resident whose heart is ABOUT to stop beating and who is ABOUT to stop breathing. Decisions about intubation should be part of the DNR order discussion. ltcpractice.com

11. How does the health care agent make these decisions? A. • Based on knowledge of preferences or previously stated wishes of the resident. “I would never want to be hooked up to machines!” ltcpractice.com

12. How does the health care agent make these decisions? B. • Based on the recent and current state of the resident. …making steady progress in recovery or slowly deteriorating in spite of treatment… ltcpractice.com

13. How does the health care agent make these decisions? C. • Based on the prognosis and known predictors of decline presented by the physician. …after hospitalization the risk of dying within one year is increased in residents who are male, dependent in ADLs (toileting, walking, etc.), have heart failure or cancer and have certain abnormal lab values…[JAMA 6.20.01] ltcpractice.com

14. How does the health care agent make these decisions? D. • Based on the agent’s own psychosocial and spiritual decisions and preferences in conjunction with the resident’s and with the support of the staff of the nursing home. ltcpractice.com

15. What if there is no health care agent and end-of-life decisions must be made? In New York State the legal representative may make these decisions but may exercise choice ONLY through signing or refusing to sign consents to treat. In these decisions “Medical Necessity” must direct care. Medical Necessity is a legal term with obvious meaning but with less clear implications when applied to the frailest nursing home resident. ltcpractice.com

16. Can the legal representative decide to refuse artificial nutrition and/or hydration for the resident? In New York State the legal representative CANNOT make these decisions unless there is “clear and convincing “ evidence that the resident would have refused this . Such evidence would have to be written by the representative, in an affidavit, and accepted by the administrator or ethics committee of a nursing home. ltcpractice.com

17. When does the health care agent make these decisions? It may be possible to make these decisions over time, carefully weighing all the preceding information sources, OR the resident’s condition might change suddenly and an immediate decision would be needed. ltcpractice.com

18. A wise health care agent will begin to discuss these decisions with the resident when agreeing to be named as health care agent.ltcpractice.com

19. Making health care and end-of-life decisions is often difficult and fraught with emotions. Information about treatment choices, risks and benefits can be complex. Still it is a vital way for you to participate in the quality of life of your loved one. ltcpractice.com

20. To discuss health care decision-making further contact the physician caring for your loved in the nursing home. ltcpractice.com