OBRA’s quality of life regulations affirm each person’s right to make choices about aspects of life significant to them, and each nursing home’s responsibility to actively assist residents in the exercise of their choice. Everyone agrees with this in theory. The rub comes when practitioners fear that honoring a resident’s choices puts that resident of risk. Choices in dining are a case in point.
Honoring residents’ choices in dining actually positions staff to get better clinical outcomes. Choices provide a road map for how to implement care interventions to meet care goals.
Carolyn lives in a nursing home in Colorado. She developed a Stage 4 decubitus ulcer 8 X 10 with tunneling and undermining, weighed only 98 pounds. She was set on not weighing over 100 pounds so staff could move her and to move herself. As her situation worsened, she stated that she didn’t want the wound to rule her life. Her doctor told her she would probably die if she kept going this way.
But she also didn’t want to die. So, she negotiated. And staff used her routines and preferences as a roadmap in their care for her. The Director of Nursing says, Carolyn agreed to meet us half way. For their part, the staff no longer try to get Carolyn to lay down; instead they help her be comfortable in her favorite chair. And while Carolyn eats healthier foods, they are foods of her choice. In other words, the essence of person centered care is being carried out.
The dietary manager honored her choice to skip lunch by finding other ways to give her protein, including chocolate milk in morning and at night and a personal supply that she keeps in her personal refrigerator. Carolyn gets extra hard boiled eggs and bacon for breakfast. The manager said: 'Between Carolyn and I, every quarter we look at other ways we can help her in her goal of wound healing and maintaining a healthy weight and try to have those options available for her.'The big lesson for the Director of Nursing was that residents know their bodies better than we do. She finds it much less stressful now that she follows residents’ leads in how to make sure they have the nutrition they need.
Accommodating David’s preferences was more challenging, because he is in danger of choking, and while he doesn’t care if he chokes, the staff do. What a shock it was for them to realize that the thickened liquids they were providing so that he could get nutrition without choking actually caused other serious problems – dehydration and sepsis – because he disliked the regimen so much that he didn’t drink enough to have sufficient fluid intake. When they called the EMT to take him to the hospital, they were sure he was aspirating, but in fact it was the restrictions on his diet that were the culprit – he wasn’t drinking.
David had been a flight attendant before illness grounded him, but he still loves going out to eat and enjoying the social nature of a meal. Their medical director advised that because David experiences joy from being around other people and going out to eat, we need to honor his choice. Why would we want him not to have that joy and that quality of life to maintain a regimen of thickened liquids or pureed foods that may or may not have an affect overall on his life span?
Once again, the dietary manager uses his preferences as the guide. David is very able to make his preferences be known. He doesn’t eat lunch so they provide double eggs at breakfast; double entrees at dinner; his favorite apple and cranberry juices; and in the morning, toast and Fruit Loops (soggier). Since they have accommodated his food preferences, he has regained his strength and recovered from the dehydration and UTI that sent him to the hospital.
These two examples illustrate the essence of new Dining Practice Standards released by the Pioneer Network in 2011, the product of a stakeholder group representing all the major practitioner associations that set standards relevant to dining. The standards call for “real food first” and honoring residents’ choices. This requires professionals to shift control to support self-direction, working with a person, not against them, building trust and rapport by listening carefully.
As Carolyn and David’s Director of Nursing said, since I stopped being such a nurse – it’s my way or the highway…it’s a win-win situation. By listening well to what residents tell us about their preferences, we are able to ensure that they have the protein and nutrition, and hydration they need to heal and thrive, in a way that it is palatable to them, that makes them happy. Honoring residents’ choices helps us do a better job of caring for them.
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