Proposal for a Course of Action
Introduction
The patient, described as a ninety year old, depressed professor, was selected for the long-term care assistance analysis is evaluated for palliative care in a hospice environment (Cohen, 2006, 235). Benefits identified in recommendation of a hospice care setting include: 1) patient request for placement outside of home; due to 2) and inability to maintain the property. The latter issue relates to both financial distress and to everyday upkeep. The patient suffers from age related fatigue and blindness, and requires pharmaceutical administration, daily.
Social factors considered in the recommendation were defined by the patient. The patient has no children, and is approximately 250 miles from the nearest relative, and 400 miles from his brother (Cohen, 2006, 235). For reasons mentioned, it is determined that the course of action focused on admission of the patient to a hospice will very likely result in positive outcomes in improved quality of life (Connor, 2009). Barriers to placement were identified according to U.S. Department of Health and Human Services guidelines to consumer directive (Stone, 2006, 186).
Consumer Direction
The importance of consumer-direction in placement of the geriatric patient supports the multi-disciplinary team model to comprehensive palliative care treatment. Consumer direction as part of the long-term care prospectus has fast received attention as patient, practice and policy communities work together toward advocacy of patient participation in managed care. The growing consumer movement targeting better geriatric health conditions in long-term care settings provides the advocates on a number of key concerns targeting costs of services, staff shortages and consumer incentives (Stone, 2000, 2006).
Hospice organizations considered in the recommendation process all provide for a policy of consumer direction within their continuum of care. The concept of consumer direction as a managed care approach extends the notion of institutional and insurance provider rules and administrative processes to the individual consumer level of decision making in the interest of patient-equity, control and autonomy (ACS, 2010).
Theories for consumer direction incorporate a cash model; offering consumers the most flexible option in payment. Empowerment fostered through the cash model increases patient choice in participatory financial decisions from a menu of services (Stone, 2006, 187). Other options in financial management include caregiver or disability tax credits; compensating the patient for monies spent on resources and formal and informal services and supports (Stone, 2006, 187). Finally, implementation of informed consent procedures as part of the standard protocol to practice in the consumer direction model ensures protection of the patient, and the administration serving from liabilities.
Multi-disciplinary Team
Evaluation of the contributions that healthcare professionals will make once the patient is admitted in the palliative care setting, informs recommendation of a multi-disciplinary care team. Due to the fact that the patient has not been consistently attended to by healthcare professionals, and requires geriatric care and administration of medication on a daily basis, from point of admission to end-of-life care, a team of specialists is the best recommended value for consumer direction (Lawton, 2001). The patient may also participate in selection of staff providing the care where viable, as well as in stipulation of constraints during and after the informed consent procedure.
Long-term Care Concerns
In the opinion of the evaluator, long-term care concerns should be addressed continuously as part of quality assurance, and in the interest of protecting the patient from any detriment that may arise during the course of action. In a Report on Nurse Staffing and Quality of Patient Care, March 2007 review of the Institute of Medicine addressing quality of health care provided in the United States outlines significant improvements to be made to guarantee effective, efficient, evidence-based, patient-oriented, and equitable care. According to the 2007 report, patient safety from injuries that may be caused by inadequate health care administration of treatment and informational services is the core subject of discussion to preventable adverse events.
Systemic improvements, rather than individual professional corrections underscore the attention to sweeping reforms in the area of healthcare allocations needed to improve the quality of healthcare and reduce costs attributable to such errors not reported to have reached $8.8 billion in national spending. At present, patient safety is part to a certification conducted by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and monitored by the voluntary National Quality Forum (NQF). The U.S. Department of Health and Human Services (DHHS) and the Agency for Healthcare Research and Quality (AHRQ) report that ‘work environment’ is a major threat to safe nursing practice in hospitals. This can impact response, endangering patient safety.
Negligence rules to medical malpractice in cases where palliative care patients age 65 or older in hospice or nursing homes are the concern, often involve circumstances of faulty medication administration. In geriatric patients, multiple doses of medication may entail substantial enhancement to quality of life or promote incapacity. Moreover, risk of secondary injuries from falls due to complications of those prescriptions emphasizes the importance of placement (Dunton et al., 2004). The patient should only be supervised and treated by a multi-disciplinary team of licensed practitioners.
The fact that geriatric patients residing in hospice settings are high risk to insurers, the patient must sign a release form to protect the organization from lawsuit (Connor, Légaré, Stacey, 2003). When a patient exhibits physiological debilitation of motor sensory or neurological capacity, unforeseen complications may pose imminent risk to an organization (Dunton et al., 2004). While most multi-disciplinary practitioners from the clinical field (i.e. licensed nurses and physicians) are provided immunity from such liability, administrative and therapeutic staff may not be.
It will be important for the patient to be covered by a reputable insurance provider to ensure that no tertiary liability will be at issue. This includes coverage for side effects induced by multiple medication ingestion prescribed by a physician. Secondary ailments or injury(s) in response to medication where patients have provided adequate care in dosage or information on self-administration, and have been forewarned of those side effects, will not obligate medical staff to potential risks (Connor, Légaré, Stacey, 2003, Dunton et al., 2004).
Still, where patients have signed release from liability in this regard, with exception of extreme circumstances of misconduct or medical malpractice, or violation of terms of prohibition to procedures or medication by the patient, it is unlikely that legal recourse will be afforded. Similar to circumstances of medical emergency, where tacit consent meets the condition of ‘reasonability’ of duty by a licensed practitioner and his/her staff.
The long-term healthcare organization must impose signatory release from liability by the patient, with adherence to the forewarning rule. Requisite consent by a legal conservator or substitute decision maker, if such a party exists, will be part of the informed consent procedure. Subsequent written and verbal instruction to pharmacological drugs and other treatments must be met to fulfill the forewarning rule in the future.
In Casarett et al.’s (2005) Making Difficult Decisions About Hospice Enrollment: What Do Patients and Families Want to Know? investigation into 237 patient and family interviews about hospice care addresses placement in an urban, not-for-profit, Medicare-certified organization (Casarett, 2005). Findings to the study show that 40% of respondents indicated not knowing “anything about a hospice” (Casarett, 2005). The study also reveals that family interveners incited enrollment decision in 57% of the cases.
Results to the study also offer insight into hospice benefit, defined by eight (8) categories of service. Patients and families ranked importance on visit frequency at 60%, payment at 59%, and the practical help 52% in priority. Principal component factor analysis outlined three distinct factors to the decision to admit: 1) impending death, 2) practical support, and 3) changes from established patterns of care (Casarett, 2005).
Information was mentioned as a priority by participants in the study, expressed as the ‘right to know’ at each phase of treatment and care. Information priorities ranked in order of importance in the study illustrate the wide range of inquiries posed by patients and their families preparing to become involved in the long-term care scenario: 1) frequency of visits; 2) payment for hospice; 3) practical support; 4) continuity of physician; 5) available sites of care; 6) continuity of treatment; 7) emotional support; and 8) spiritual support (Casarett, 2005).
In addition to general overview information in informed consent procedure, the research on palliative care address the anxiousness of patients referred to hospice services. This is especially the case when they and their families have not been exposed to palliative care approaches to patient intervention. If the general trend within healthcare policy is supported by evidence based practice, Issues and Dilemmas in Conducting Research with Vulnerable Home Hospice Participants described in Dobratz (2003) reveals attrition and range of needs persist that are not always captured in survey.
For instance, clinical diagnosis of patient’ symptoms often precluded the informed consent process, so that questions about prescription administration and treatment follow prior prognosis. Geriatric patients also at times do not recall prior medical or healthcare intervention, and this can add to confusion about the course of action. Permission to discuss information involving patients as part of a joint decision model illustrates the scope of patient and/or third party intervener/ agents inclusion in hospice treatment planning, as provided fro in the U.S. Patient Bill of Rights, “if it is medically inadvisable to provide such information, it will be given to a legally authorized representative” as counter-productive to active patient involvement in wellness (NIH, 2010).
Definition of informed consent in follows the Patient Bill of Rights and articulates federal rules on practitioner-patient agreement. Incapacitated patient parties are protected under the bill in respect to non-disclosure and privacy. The course of action in this case includes hospice recommendation, and has been reviewed according to the Doctrine of Apparent Agency (DoAA) and Familial Advance Planning Evaluations (FAPEs) recommendations on admission (Perry, 2002). The evaluation is meant to assist the individual patient and family in facing incapacity during the end-of-life transition (Perry, 2002).
The FAPE model is relevant to The Patient Bill of Rights in respect: “1) To safe, considerate and respectful care, provided in a manner consistent with patient beliefs; 2) To expect all communications and records pertaining to patient care will be treated as confidential to the extent permitted by law; 3) To know the physician responsible for coordinating patient care; 4) To receive complete information about diagnosis, treatment, and prognosis from the physician, in terms that are easily understood; 5) If it is medically inadvisable to provide such information, it will be given to a legally authorized representative; 6) To receive information necessary for you to give informed consent prior to any procedure or treatment, including a description of the procedure or treatment, any potential risks or benefits, the probable duration of any incapacitation, and any alternatives; and 7) Exceptions will be made in the case of an emergency” (NIH, 2010).
DoAA rules enforce classification and ranked order of authority of interveners defined as: 1) Agents and Principals (i.e. physician/parents v. ex-husband); 2) Agents and the Third Parties with whom they deal on their Principals' behalf; and 3) Principals and the Third Parties when the Agents purport to deal on their behalf (Showalter, 2008). The guidelines to ethical shared decision-making are advanced in partnership with The U.S. Department of Health and Human Services (HHS) which enforces the Federal privacy regulations commonly known as the HIPAA Privacy Rule (HIPAA). HIPAA is the mandated, provider based decision model to informed consent, and provides the guidelines for inclusion of patient diagnosis and care of the patient, family, friends or others involved in ongoing care and payment (HIPAA) (DHHS, 2010, 2013).
Services
The services available through the geriatric hospice organization are designed to benefit individual patients through participation in care plan and service development. Based on a flexible consumer direction service model, such organizations normally provide professional managed service packages, and allow for individual purchasing of medical devices and pharmaceuticals from vendors, personal caretaker involvement (Stone, 2006). This is the general trend amongst private, publically funded and community-based care programs. The consumer direction continuum model establishes the baseline service framework for recommendation.
Recommendations
During evaluation of the patient for placement in the long-term care environment, the patient’s current healthcare picture and residential status were measured for quality of life. The patient has been deemed to quality for hospice admission. Recommendation of an organization focusing on geriatric consumer direction and provision of services in a comprehensive, multi-disciplinary care team setting is advised. Barriers discovered to placement were few, with the exception of depression which is concluded to be best managed in the healthcare treatment environment. The patient’s finances are limited, so that consumer direction of payment scale options is an immediate priority to narrow the selection. Consumer choice of healthcare providers from a network of practitioners will be conducted in coordination with staff and designated party(s) within the Patient’s social support system.
References
Casarett, D., Crowley, R., Stevenson, C., Xie, S., & Teno, J. (2005). Making Difficult Decisions About Hospice Enrollment: What Do Patients and Families Want to Know?. Journal of the American Geriatrics Society, 53(2), 249-254. doi:10.1111/j.1532-5415.2005.53110.x
Cohen, E.S. (2006). Response to Quality: differing definitions. In: S. R. Kunkel and Wellin, V. eds. Consumer Voice and Choice in Long-term Care. New York, NY: Springer Publishing Company, 234-236.
Connor, A., Légaré, F., & Stacey, D. (2003). Risk communication in practice: the contribution of decision aids. BMJ: British Medical Journal 327 (7417), 736-740.
Connor, S. (2009). Hospice and Palliative Care: The Essential Guide (2nd ed.). CRC Press.
Dobratz, M. C. (2003). Journal of Nursing Scholarship, 35(4), 371-376.
Dunton, N. et al. (2004). Nurse staffing and patient falls on acute care hospital units. Nursing Outlook 52 (1), 53-59.
How is shared decision-making different from informed consent? (2010). American Cancer Society. Retrieved from: http://www.cancer.org/Treatment/FindingandPayingforTreatment/UnderstandingFinancialandLegalMatters/InformedConsent/informed-consent-shared-decision-making
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2010). Retrieved from: http://www.jointcommission.org/
Kunkel, S. R. and Wellin, V., eds. (2006). Consumer Voice and Choice in Long-Term Care. New York, NY: Springer Publishing Company.
Lawton, J. (2001). Gaining and Maintaining Consent: Ethical Concerns Raised in a Study of Dying Patients. Qualitative Health Research 11(5), 693.
National Certification Corporation (NCC) (2010). Retrieved from: http://www.nccwebsite.org/
National Quality Forum (NQF) (2010). Retrieved from: http://www.qualityforum.org/
Nurse Staffing and the Quality of Patient Care (2007). AHQR Evidence Report. National Library of Medicine. Retrieved from: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=erta151&part=A237502
Patient Bill of Rights (2010). National Institute of Health (NIH). Retrieved from: http://www.cc.nih.gov/participate/patientinfo/legal/bill_of_rights.shtml
Patient’s Guide to the HIPAA Privacy Rule (2010). The U.S. Department of Health and Human Services (DHHS). Retrieved from: http://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/consumer_ffg.pdf
Perry, S. J. (2002). The role of proxies in treatment decisions: evaluating functional capacity to consent to end-of-life treatments within a family context. Behavioral Sciences & the Law, 20(3), 235-252.
Showalter, J.S. (2008). The Law of Healthcare Administration. Chicago, IL: Health Administration Press.
Stone, R.I. (2006). Chapter Twelve: Common or Uncommon Agendas: Consumer Direction in the Aging and Disability Movements. In: S. R. Kunkel and Wellin, V. eds. Consumer Voice and Choice in Long-term Care. New York, NY: Springer Publishing Company, 186.
U.S. Department of Health and Human Services (DHHS) (2013). Retrieved from: http://www.hhs.gov/
