Even in a nursing home, palliative care can be used to ease the way at the end of life

When a person moves out of their home and moves into a nursing home for their long-term care, they become a resident at the facility, because the long-term care facility (LTCF) is their new home. The resident  will receive mail there, can submit an absentee voting ballot from there, receive personal visitors and telephone calls there. This is why federal law and state law are couched in terms of “Resident’s Rights” rather than “Patient’s Rights.”

Many articles and studies can be found which show that at the end of life, people have a preference to die at home. If the “home” is a nursing home, facilities must develop an individualized care plan that is geared to the particular resident’s needs and goals. If the goal is comfort and avoiding medical interventions, the care plan can be worked around a palliative care plan which takes into account things such as inevitable weight loss, avoiding the insertion of a feeding tube, and treating the symptoms without requiring hospitalization to detect the cause of a condition (such as a fever). The health care proxy can refuse medical evaluations when detecting the cause will only lead to treatment which is unwanted. The point of palliative care is comfort care and the avoidance of a hospitalization, which can be a traumatizing transition for a resident that can lead to further complications and unwanted interventions.

The Centers for Medicaid and Medicare Services (CMS) publishes the RAI as the methodology for long term care facilities to assess and develop services. Look at page 1-9 in particular, section c.: “Identification of Outcomes—Determining the expected outcomes forms the basis for evaluating resident-specific goals and interventions that are designed to help residents achieve those goals. This also assists the interdisciplinary team in determining who needs to be involved to support the expected resident outcomes. Outcomes identification reinforces individualized care tenets by promoting the resident’s active participation in the process.” CMS MDS and RAI nursing home (May 2013)

The resident’s doctor can issue standing Orders for the resident’s chart such as an out-of-hospital DNR (Do Not Resuscitate) or a DNH (Do Not Hospitalize). The health care proxy (and the resident, if possible) should have a discussion about the LTCF’s policy on Do Not Hospitalize orders. Under what circumstances would the facility require that the resident be transferred to an acute care facility? Insist on a thorough exploration with the facility’s team to determine what alternatives the Home can offer that would keep the resident comfortable, keep the other residents safe, and enable the resident to remain “at home.”

These techniques can help the health care representative carry out the resident’s wishes. A great deal of thought needs to be put into such planning, because health conditions can take unexpected turns. As always, creative advocacy based in the law is the key to success.

For legal advice and representation on elder care issues and nursing home care plans, call us at 732-382-6070



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