SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.
"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.
Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.
Smoking
Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.
Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).
One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.
A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.
On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.
Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"
In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).
Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.
Dysphagia
In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.
Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.
In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.
In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.
One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."