Bioethical issues and the long-term-care facility.
Nursing Homes Long Term Care Management
| March 01, 1988 | Kaufman, Anna |Copyright
Death and dying have now moved from being a taboo subject to one that is the basis for books, research studies, magazine articles, and television programs. In the past, death was a more private matter, usually occurring at home. Now, over 85 percent of deaths happen under medical supervision, usually in a hospital or nursing home. Another change that has taken place with time is the medical developments that have made death more a matter of deliberate decision; e.g., organ transplants, kidney dialysis. Still another change has begun to be apparent. Until fairly recently, with a doctor caring for a person, the patient and his family often deferred to the doctor's decision. As a social work consultant in nursing homes, this writer has become aware of more and more people beginning to be more actively involved with medical decisions affecting them. They have been asking more questions of their doctors, and asking for more medical information. That applies not only to the patients, but to their families as well. Medical malpractice cases have become more frequent, making it increasingly necessary for physicians to share medical information with the patient and his family, and to involve them more in medical decisions. The issue of bioethics and bioethical decisions has become vitally important. With elderly residents of nursing homes, there are specific areas of medical decisions for which bioethics have to be given serious consideration. Added to that is the factor of whether an elderly person is mentally alert or has deficiencies in his cognitive capacities. Two major matters of frequent occurrence in the nursing home are (1) the use of a NG tube when a patient is not taking adequate nourishment and/or fluids orally; and (2) sending the patient to an acute hospital for more aggressive treatment that cannot be provided in the nursing home. The foregoing present dilemmas for the facility as well as for the physician. Not only do they have to be concerned about the patient and his welfare, but they have to consider the possibility of legal actions taken against them by government regulatory authorities. Because of the latter concern, families' and patients' wishes may have to be ignored. Also, the physician at times may find himself caught between pressures from the family and/or patient and pressures from the facility over fear of being cited by the regulatory agency. Here is an example: Mr. M., an 80-year-old, terminally-ill cancer patient had reached the point of neither being able nor wanting to eat. Two years earlier, when he was first diagnosed, he had discussed with his wife and daughter that should he reach a point in his illness that his death was imminent, he did not want to be kept alive. He had been in one nursing home and when the doctor, complying with the family's wishes, refused to insert a NG tube, the facility found a reason to transfer him to an acute facility (when the primary doctor was not on call). Upon his being ready for discharge from the acute facility, the original nursing home in formed the hospital discharge planner that it didn't have an available bed for the patient. The physician arranged for him to be admitted to another facility. To reassure the anxious administrator of that facility, the doctor stopped by daily to see the patient, and to document his chart. Since I served the facility as its social work consultant, at the physician's request I spoke with the patient's wife. (The patient, by this time, was not mentally aware enough for my involvement with him). I documented the chart; and more of my efforts went to help the administrator with her fear of possible repercussions from the government. While I discussed with the administrator the importance of respecting the patient's and family's rights, I emphasized the need for complete and detailed...
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