A person who moves into a nursing home is referred to as a “resident” for a reason — this is their new home. At the end of life, the health care representative (or the patient himself) may be wondering whether there is a way to ensure that he can “die at home” in his bed instead of in a hospital. Paving the way for a quiet end will require teamwork and collaboration between the health care decision-maker and the nursing home’s decision-makers. Here are some tips.
The Centers for Medicare and Medicaid Services (CMS) issued a specific, lengthy, updated policy on this issue. ” The facility is required to establish, maintain, and implement written policies and procedures regarding the residents’ right to formulate an advance directive, refuse medical or surgical treatment and right to refuse to participate in experimental research. In addition, the facility is responsible for ensuring that staff follow policies and procedures.” The policy goes on to state: ” RIGHT TO REFUSE MEDICAL OR SURGICAL TREATMENT. If a resident (directly or through an advance directive) declines treatment (e.g., refuses artificial nutrition or IV hydration, despite having lost considerable weight), the resident may not be treated against his/her wishes. If a resident is unable to make a health care decision, a decision by the resident’s legal representative to forego treatment may, subject to State requirements, be equally binding on the facility. A facility may not transfer or discharge a resident for refusing treatment unless the criteria for transfer or discharge are otherwise met.
” If a resident’s refusal of treatment results in a significant change in condition, the facility should reassess the resident and modify the care plan as appropriate. The facility is expected to assess the resident for decision-making capacity and invoke the health care agent or legal representative if the resident is determined not to have decision-making capacity. Once the decision-making capacity is assessed, the facility is expected to determine and document what the resident is refusing, to assess the reasons for the resident’s refusal, to advise the resident about the consequences of refusal, to offer pertinent alternative treatments, and to continue to provide all other appropriate services. The resident’s refusal of treatment does not absolve a facility from providing other care that allows him/her to attain or maintain his/her highest practicable physical, mental and psychosocial well-being. For example, a facility would still be expected to provide appropriate measures for pressure ulcer prevention, even if a resident has refused food and fluids and is expected to die.”
What can the advocate do? The health care representative needs to find out what the nursing home’s policy is about “Do Not Hospitalize” orders (DNH). Are there certain circumstances in which the facility will require a transfer to the hospital? If the patient stops eating, and weight loss is inevitable, and the patient had previously signed an Advance Directive/Living Will, how will the nursing home accommodate a request to refuse a feeding tube? What are the facility’s obligations to patient safety? Discuss the process for periodic revision to the Plan of Care so that the Goals of Care are simply “comfort care” rather than “treatment” of new conditions? Find out the process for utilizing palliative care. Find out how to make sure that every single member of the nursing staff will know that the patient is never to be transported to a hospital in the event of respiratory arrest, cardiac arrest, refusal to eat, etc. Of course, make sure that the physician has entered a DNR (Do Not Resuscitate) order in the patient’s chart. Also, discuss the process by which the facility would normally call in a medical specialist; the patient has the right to refuse such unnecessary evaluations if the goal is “no treatment.”
Each case is unique, and the goal is for the entire team – family, nursing, social services – is to aide the patient to fulfill their wishes and remain as comfortable as possible as the end approaches.
Call for advice and representation in elder care planning and end of life planning … 732-382-6070