Thursday, December 6, 2012

What do you know about long-term care?



It is shameful - the horror stories about abuse in long-term care. The myths and the fearmongering are even worse. There is much joy in long-term care. Laughter, and kind, caring individuals who look after our loved ones. You know, also, that if it bleeds it leads
CARP, which publishes Canadian Zoomer Magazine, with many false American references, continues to assault us in the area of healthcare. It seems to me that CARP needs to understand that healthcare in Canada is vastly different from that of the USA. Moses Znaimer, Toronto media baron, is on the bandwagon advocating for the ability of one to end their own lives. I think it more important to determine the Barriers to a good death.

Long-term care homes across Canada...

Here is the latest (Nov. 2012) article that had me upset.
[PDF] 

Long-term care homes across Canada...

File Format: PDF/Adobe Acrobat - Quick View
Long-term care homes across Canada have been rocked by horrifying reports of resident abuse. Why does the industry seem impervious to change?



CARP published an article in the November issues that disparages long-term care (LTC). Not all seniors in LTC are assaulted. Not all are at risk for the many things that they purport to be wrong.

Yes. Most of our retirement homes and LTC are for-profit in Ontario. (Approximately 500/600 are for-profit). That said, we have a good system to report abuse. (Myths around elder abuse, complaints about LTC). 
The incidents of abuse are truly few and far between. When they hit our most vulnerable seniors, they hit home and they hit the front page. We do not have accurate Canadian statistics of the incidents of financial, emotional, social abuse. In fact, many seniors engage in self-abuse than are abused by family members. Those with addictions, living in poverty and unable to navigate the system.

I was interviewed for a TVOntario program recently (TVOntario Video: End-of-life care), End-of-life care for those in poverty. There are ways to improve the care we get in LTC, as well as in Home Care, and increase the likelihood that we can prevent abuse of seniors.

Regulate and Track PSWs
Firstly, improve the training and begin regulation of personal support workers (PSW) who give most of the care. There might only be one nurse per shift, but many PSWs who are accountable to the busy nurse. PSWs change our senior's incontinence products, they get the, dressed in the morning, bring them to meals, feed them, if necessary. Yet, they are trained with a 14-module certificate program. They do not have a college or university degree. They know little of the psychology and sociology of geriatrics. Some employers insist on professional development, other do not. Part of this is being able to track those with little education, who are inclined to physically, emotionally, or financially inclined to abuse a senior. They are able to go from employer to employer, with no accountability. Aggressive professional caregivers in the healthcare field can do much harm in the name of good.

Legislate the Reporting of Abuse
Further, make it a requirement to report someone they see abusing another person, as we in education must do for our children. Now, the barrier to this is being able to differentiate seniors with dementia who believe they are being abused, from those who are truly unable to manage their money or their other ADLs. I cannot tell you the people, like my father, who are unable to understand what it is that they do not know or are unable to do anymore. He was unable to manage his finances but refused to hand over control of his banking, despite me having Power of Attorney.

Medical Upgrading
Secondly, both doctors and nurses must remain current on geriatric practices, end-of-life care and disavow themselves of the myths around pain management. I have had contact with many families whose physicians refrain from supplying them with a Pain Management Kit in their homes with a palliative patient. In fact, doctors are terribly reluctant to understand Comfort Measures, and fail to acknowledge that a patient is palliative. see: Signs of Pain - Pain Relief in Long-Term Care

disease trajectories
We know much about disease trajectories, yet little of this information is communicated to patients and their families. We know much about assessing the time of end-of-life, but physicians are reluctant to require nursing staff to administer these tools. I have found several:


Palliative Care and Pain Assessment Tools



I will never forget the physician who entered my client's hospital room, examined her in her coma, on CADD with morphine pump, her pain managed, and declared, 'She just won't die.' Hers was a good death. His was a criminal attitude.

Have you ever heard a physician declare, "I don't know, but let's find out." As an educator, I aid this to my students all the time. For physicians and nurses, with patients who face complex comorbidities, it is crucial that they understand end-of-life care, comfort measures, the important of 'do no harm', and when to create an atmosphere of support, rather than poking, prodding and treating patients to death. When I had a Nurse Practitioner, as part of my Family Health Team, she did her research for me, as does my current physician.

FIPPA vs. PHIPA

The healthcare profession has been handcuffed by the Freedom of Information and Protection of Privacy Act (FIPPA). They create policies, whether they be NGOs, profits, or non-profit organisations, that ignore the basic tenets of the Personal Health Information Protection Act (PHIPA), which says that if a patient is liable to engage in self-harm, they must be protected. In the case of a senior, with dementia, they are afraid of giving them a psychiatric dementia test, to determine their risk. My late mother and father's CCAC charge nurse was one such. Dad was beyond making adult, sentient decisions about his care, as have been several of my clients, yet they continue to believe more in protecting their rights to choose than determining that PHIPA over rides any privacy in order to speak truth to family members, who are trying to protect a loved one from themselves.

Patient navigators, frail seniors

This may be the way to improve the lives and deaths of those who cannot understand the system and manage their care. These are not people who are trying to dole out healthcare support to frail or dying patients, but people who will help them ask the right questions about their care and advocate for what is best for the patient, not the system or the family. Sometimes, it might boil down to helping a patient and their family have a good death, which is something I advocate for with my hospice clients.

Do you know the answers to the Five Questions?
Have you discussed this with your family?
My family knows my desires. No extreme measures. Do not put me on a feeding tube or hook me up to machines. That is my preference.
See also: The Conversation Project.

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