The Right To Live: Part II

Necessary Policies to Protect Seniors

In our March issue of Elder Voice, we discussed the issue of decisions being made about end of life without the input of the person or their family. In this issue, we follow up with a recommendation for policies at both government and an institutional levels which would help to protect people from having decisions made about them without their consent.

In brief, policy and procedural guidelines should be developed which clearly state that except under extraordinary circumstances, medical personnel should never independently deem someone to be at the end stage of life and to receive comfort care only. Examples of extraordinary circumstances might include: 1. there is no family, friend, or other person available to consult; 2. the individual is unable to participate in the decision; or 3. a decision must be made immediately.

Otherwise, whether the individual in question is in a nursing home or in hospital, when a change in condition occurs or a situation arises that requires a decision on whether or not to withhold treatment and institute comfort measures only, there should be a health care regulations that dictate policy and procedures for making that decision. We recommend the following:

1. The person about whom the decision is being made is to be consulted as the first step.
2. With the individual’s permission, family or other involved next of kin should be notified of any change in condition or situation in which the withholding of care and treatment is considered.
3. If the individual is not able to give direction, then care providers must involve significant others in a discussion of the situation. These may include family, friends or professionals who are involved in their life and do not have to be limited to those having legal power to make the decision even though those individuals have the ultimate responsibility.
4. Discussion with significant others should help them focus on what that person wants or would have wanted rather than based on grief or other considerations on the part of those making the decision.
5. When a person is unable to give direction, discussion should also take into account the individual’s current life. Issues such as mood, activity level, social interactions, independence, cognition, or mastery might be used to assess quality of life, balanced against previously expressed values and what they would have wanted or said had they been able to do so.
6. What someone might have said in the past should not necessarily take precedence over what the individual exhibits and says in their current situation or over what family, others, and care providers see in the individual’s current life.
7. Medical personnel should discuss all alternative treatments and investigations which might lead to a different outcome, as well as the physical and psychological risks and potential outcomes of those alternatives, including the risk of pain or suffering.
8. The process that led to the decision to begin providing comfort measures only should be documented with a timeline of that process in the individual’s chart if they are in care or hospital. The documentation should include how the decision was made, who was involved in the decision, and what attempts were made to elicit agreement from the individual when possible, and when not, what attempts were made to make the decision based on the person’s history and values.

Medication Usage and Seniors: Present Practice and Necessary Regulations

The recent series on care and services for seniors in the Vancouver Sun included a section focusing on medication usage. In particular it highlighted anti-depressants and anti-psychotics being used to control behaviour when there has not been a proper diagnosis of depression or psychosis. This is a complicated and nuanced discussion. However, we believe that, similar to the situation in which someone’s life is being discussed, policies and procedures should be developed in regards to use of any medication, but in particular to the use of anti-depressants and anti-psychotics.

Any time that a medication is initiated or changed, this indicates a change in the individual or the perceived need for intervention in some area of their health and well being. Reasons for medication changes can include:

–a medication is not working
–a condition is resolving or has been resolved
— there is a new condition, diagnosis, or concern
— there is a change in mood
— there is a change in behaviour
–pain has presented or intensified
–toxicity is present
–harmful medication interactions are observed
— changes in cognition
–a more effective medication is available
–a person may have suffered unintended or strong side effects, such as falls, a lack of appetite, a change in blood pressure, or other symptoms difficult to tolerate.

What we can see from the above is that any of these reasons for medication initiation, discontinuation, or change are serious. This leads us to recommend a regulations that dictate policy that stipulates:

1. Whenever there is a change in medication, the resident and family member/person responsible should be notified before the change is instituted.

2. The person or people being informed should be informed about:

• the indicators for the change
• the desired effect
• potential side effects
• risks beyond side effects

3. In the case of medications used to control mood or behaviour, people should be informed as to review dates for effectiveness, what other efforts have been made to address the issue, and what to do if they are not in agreement.

There are many times when anti depressants and antipsychotics are an appropriate choice of intervention, especially after other attempts at problem solving have not been effective. They are not a substitute from appropriate care and staffing levels. We believe that following these policies would lead to a reduction in the inappropriate use of anti depressants and antipsychotics, better resident and patient care, and a better quality of life.