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Difference between revisions of "Care Planning in Residential Care"
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Care Planning in Residential Care (view source)
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* must not be mandatory - an adult must not be required to have an advance directive as a condition of receiving any good or service. | * must not be mandatory - an adult must not be required to have an advance directive as a condition of receiving any good or service. | ||
* may not include anything that is prohibited by law or an instruction to omit to do anything that is required by law. | * may not include anything that is prohibited by law or an instruction to omit to do anything that is required by law. | ||
* cannot include instructions about any types of health care restricted for a temporary substitute decision-maker. | * cannot include instructions about any types of health care restricted for a temporary substitute decision-maker. | ||
==Consent and Advance Care Directives== | |||
As noted in the chapter on admissions, in recent years, more and more care facility operators are inquiring at admission whether the person has an advance directive. Accreditation processes and mandated health care system tools such as the Resident Assessment Instrument - Minimum Data Set (RAI MDS) may leave the health care providers with the belief the residents must have advance directives, and may leave them with erroneous or incomplete information about the difference between informed consent and advance care plans. | |||
Unfortunately residents and families are sometimes given the impression the resident must have an advance care directive or other advance care planning as a condition for admission or to remain there. The law is clear- advance care directives are not mandatory and cannot be required as a condition of receiving services. The Public Guardian and Trustee specifically notes: | |||
:''“You do not have to make an advance directive. It’s your choice. It is one tool that you can use to plan for your future. A service provider may not require you to make one as a condition of receiving goods or services.”'' | |||
===What can care providers do?=== | |||
Just because a senior has moved into a long-term care facility does not automatically mean that he or she needs an enduring power of attorney, representation agreement or advance directive. The senior may continue to manage his or her own finances during any period of time that he or she is a resident there. However, when a senior moves into a long-term care facility, it may be a good time to consider whether he or she wants to prepare these documents to address possible future needs or whether he or she wants some help with financial management or other decisions, now, while he or she is still capable. | |||
===What are the capability requirements to make an Advance Directive?=== | |||
The person must be capable of understanding the type of health care instruction it deals with and the consequences of giving or refusing consent to it. The person must also understand that if the person makes an advance directive and the instruction applies to the specific health care situation arising while the person is incapable, a health care provider will only follow the instruction. They will not select someone to be a temporary substitute decision-maker. | |||
==Common Areas of Misunderstanding for Advance Health Care Consent== | |||
===Standardized Forms=== | |||
In recent years British Columbia has been moving to develop standardized health care planning and end of life intervention orders. A recent review of health care planning and related policy documents in use in Canada, including one from British Columbia pointed out a number of common errors in the forms: | |||
* They failed to distinguish between and confused consent to treatment, prior capable wishes, values and beliefs (advance care planning), and physician orders based on the standard of care; | |||
* They left the erroneous impression that substitute decisionmakers can express new wishes on behalf of residents, whereas they can only recount prior capable wishes expressed by the person; | |||
* They seemed to suggest that physicians can directly implement advance directives, without utilizing the substitute decisionmakers or anyone else to interpret whether the advance directive actually applied in those circumstances.* | |||
One of the documents reviewed was Medical Orders for Scope of Treatment (MOST) developed by Fraser Health and promoted by the Ministry of Health. This is a system of medical orders and standardized forms to be used across care settings that record physicians’ orders regarding end-of-life medical interventions, along with standardized forms recording patient advance care plans. The MOSTs are to be reviewed at least once a year. | |||
Tucked in the documents among many details is the observation “As long the adult is capable of providing consent, consent should always be sought from the adult directly and not from their MOST order, Committee of Person/Personal Guardian, Representative, Advance Directive, or Temporary Substitute Decision Maker (TSDM).“ This point is very important, but it is given little prominence in the overall scheme. Like many other policy and education documents on advance care planning, MOST and the policy documents that accompanied it contained the common legal errors noted above. | |||
===Tick Box Forms=== | |||
Advance care planning and advance care directives, in particular, have been widely promoted in health. The original efforts began as ways of expressing patient autonomy. In recent years, the rationale in health care policy shifted more to cost reduction, in part predicated on the belief that older adults especially at the later stages of life were “using more than their fair share of health resources”. | |||
Many advance care planning forms are tick-box forms: forms which require patients to choose from a narrow field of pre-selected options for future care. The use of tick-box advance care planning forms appears to be widespread. | |||
It has been pointed out these forms unduly restrict the wishes that may be solicited from people, and the information expressed in these forms may not be particularly useful to a future substitute decisionmakers (“if indeed one is consulted”). | |||
The forms also generally make no attempt to place the person’s expression of wishes in the context of their current health condition, or to discuss the risks and benefits of treatment. Instead, they simply request that people express their future wishes about, for example, whether they want to be hospitalized and receive antibiotics, without grounding the application of that wish in likely hospitalizations relating to the patient’s present health condition. It has been pointed out that these level-of-care forms in particular seem to be used frequently as consents although they are being portrayed as advance directives. They are completed without the information required for a valid informed consent. | |||
{{REVIEWED | reviewer = BC Centre for Elder Advocacy and Support, June 2014}} | {{REVIEWED | reviewer = BC Centre for Elder Advocacy and Support, June 2014}} | ||
{{Legal Issues in Residential Care: An Advocate's Manual Navbox}} | {{Legal Issues in Residential Care: An Advocate's Manual Navbox}} | ||
