Disclosures for Lisa Milliken - MemberClicks€¦ · Food prepared in a form designed to meet individual needs ... nutritional interventions to meet the resident’s nutritional needs,

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I have commercial interests in the following organization(s):

Education Specialist

Select Rehabilitation -What the company does? (one sentence)

Disclosures for Lisa Milliken

Lisa Milliken, MA, CCC-SLP, FNAP, CDP

Education Specialist

Managing the Risks while Honoring

Residents’ Person-Centered Diet Choices

Course Objectives

At the conclusion of this course, participants will be able to:

Cite the CMS regulations which reference the resident rights

regarding their choices and decisions affecting their care

List the disadvantages of diet waivers and advantages of

recommended interdisciplinary documentation of the

residents’ choice

Identify the steps of care planning and informed consent

regarding a resident’s choice of dietary plan

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The CMS Regulations

Person-centered Care & The Resident’s Rights

Assuring Person Centered Care

2013: CMS released a memorandum on New Dining Practice

Standards to increase focus on nursing home residents’ food

choices

2016: CMS issued regulations for LTC facilities requiring

person-centered care and improved safety for residents

Person-centered care includes “resident preference”

Person-centered care becomes more complicated if the resident

has dementia or other cognitive difficulties

Are those residents capable of making an informed choice?

Resident Rights Required

Choose activities and schedules (F-Tag 561)

Interact with members of the IDT, friends and family both inside and

outside the care community (F-Tag 562, F-Tag 561)

Make choices about aspects of his or her life in the care community

(F-Tag 561)

Participate in care planning (F-Tag 657)

Refuse treatment (F-Tag 578)

Achieve the highest practicable level of well-being (F-Tag 675)

The same rights as any resident of the US (F-Tag 550)

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Each resident receives and the facility provides:

Food prepared by methods that conserve nutritive

value, flavor, and appearance

Food and drink that is palatable, attractive, and at a

safe and appetizing temperature

Food prepared in a form designed to meet individual

needs

Food that accommodates resident allergies,

intolerances, and preferences

§483.60 Food and Nutrition Services

§483.60 Food and Nutrition Services (cont.)

Appealing options of similar nutritive value to

residents who choose not to eat food that is initially

served or who request a different meal choice;

‘alternative’ or ‘substitute’ meals, choices and options

and “at times of the resident’s choosing.”

§483.60(d)(5)

Drinks, including water and other liquids consistent

with resident needs and preferences and sufficient to

maintain resident hydration

Example Surveyor Guidance

INVESTIGATIVE SUMMARY AND PROBES

§483.21(b)(2)

Ex: Did the dietitian and speech therapist determine

the optimum textures and consistency for the

resident’s food that is nutritionally adequate and

compatible with the resident’s oropharyngeal

capabilities and food preferences?

(If not, F657- Care Plan Development and Revision)

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Examples of Severity Level 4

Noncompliance: Immediate Jeopardy to Resident Health

or Safety include but are not limited to:

Dietary restrictions or downgraded diet textures, such

as mechanical soft or pureed textures, were provided

by the facility against the resident’s expressed

preferences and resulted in substantial and ongoing

decline in food intake resulting in significant or severe

unplanned weight loss with accompanying irreversible

functional decline to the point where the resident was

placed on Hospice. (F692- Nutrition/Hydration Status)

Example Surveyor Guidance

§483.10(c), F552, Right to Make Treatment Decisions

o Determine if the facility addressed the resident’s right to

refuse treatment, including drinks and thickened fluids.

§483.25(g)(1)-(3), F692, Nutrition/Hydration

oDetermine if the facility has managed the resident’s

nutritional interventions to meet the resident’s

nutritional needs, while accommodating the resident’s

allergies, intolerances, preferences, or need for a

therapeutic diet.

The Legal Perspective

Defining the terminology

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Terms Often Used Interchangeably

“Competence”: a legal term; our legal system supports the

concept that all people are competent to make decisions

unless a court determines otherwise

“Decision-making capacity”: a clinical term that is

determined by a physician or sometimes a psychologist,

based on a specific medical situation

When a resident refuses the recommendation of the

SLP and is at risk for aspiration or malnourishment…

Two Highly Held Values

• Autonomy: It is the resident’s body, and the resident has

the right to decide what medical treatments to accept or deny

• Beneficence: Clinicians must make a recommendation

that is clinically sound, evidence-based and made for the

good of the resident

• Conflicts involving nutrition or hydration recommendations

typically can involve tension between those principles

• Wagner notes: “Depending on the circumstances,…

AUTONOMY TYPICALLY TRUMPS BENEFICENCE”

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Legal Requirements vs.

Person Centered Care

What are the Risks?

Aspiration?

Choking?

Hospitalization?

Death?

Preventing Resident’s Quality of Life?

Dehydration?

Malnutrition?

Resident’s preference not being allowed?

Breakout

Group

discussion

Get in groups of 2-3

Come up with a list of what

you think could cause

aspiration or choking

Think of all options OTHER

THAN the diet choice or type

of liquid

We’ll convene back in a few

minutes to hear your thoughts

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Scenario: Resident should have nothing by mouth, and

the physician recommends a feeding tube

Consider these points:

• The leading cause of death among tube-fed residents is

aspiration pneumonia

• Other risks from feeding tubes:

• The increase in reflux caused by less swallowing by

mouth and changes in the tone of the esophagus

• Muscle disuse atrophy due to lost muscle memory and

strength from not swallowing

Cited Risk Factors For

Aspiration Pneumonia

Dependent for feeding

Dependent for oral care

# of decayed teeth

Tube feeding

More than one medical diagnosis

# of medications

Smoking

Dysphagia (Langmore, et. al, 1998)

Strongest to weakest predictors of

pneumonia in NH pts:

Suctioning use

COPD

CHF

Presence of feeding tube

Bedfast

High case mix index

Delirium

Weight loss

Swallowing problems

UTIs

Mechanically altered diet

Dependence for eating

Bed mobility

Locomotion

# of medications

Age

In addition to CVA and tracheotomy care, which were inversely predictive of pneumonia.

(Langmore, et. al, 2002)

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“I have to protect my license.”

“No, you have to present your professional opinion based on

your skill, education and experience, and do so in ways

residents can understand and articulate their choice based on

having all the information.”

Mary Casper, Corporate Rehabilitation Consultant for HCR ManorCare As quoted in ASHA Leader article

Informed Consent &

Care Planning for

Resident Choice

Diet

Waiver Or

Waive the Waiver

“Waivers are not, in fact, protective and can actually

interfere with the provider-resident relationship.”

“Case law suggests these documents—sometimes called

“negotiated risk agreements”—are unenforceable, improper

and invalid”

Eric Carlson

Directing attorney w/the nonprofit Justice in Aging

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Disadvantages of Waivers

Waivers create a divide between therapists (or nurses) and

elders and their families

In some cases, signing a waiver means treatment ends

They often focus on an instance of education rather than

continual education

A dysphagia diet is a type of treatment. Automatically assuming

that someone will adopt the dysphagia diet when we

recommend it violates elder’s rights

Wynn, R , Gray Matters, July 15, 2014

Carlson recommends:

Providers should document:

A choice has been given to the resident

The resident has received adequate information

When presented with that information, the resident

has made a choice

If there are negative outcomes, the provider can point

out that the resident made this choice

When the resident has selected a course of action

other than the one recommended by the SLP…

The “Ethical Concerns” section of ASHA’s Adult

Dysphagia Practice Portal advises SLPs to:

Educate the involved parties about possible health

consequences and to document all communication with

the resident and caregivers

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Case Studies

Swallowing Study results are not for the

rest of time (Ms. Virginia)

Dx of Parkinson’s Disease

Receiving all nutrition via PEG tube for over a year

Family requested PO intake for a Birthday outing

Med Hx review: Tube placed after hospitalization over a

yr ago, with note to reassess in 6 months

Just Say NO to Waivers (Ms. Lucy)

Repeat episodes of aspiration-related pneumonia

Family :“Mom loves water. We cannot take that away from her”

Instrumental assessment not completed at the hospital due to multiple

past studies and resident/family refusal

Bedside Eval: Extremely SOB when combining food with thin liquids;

when drinking thin water in isolation and small drinks her tolerance

was increased

Care plan was updated to include thorough oral hygiene regiment to

reduce bacteria load and water protocol

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Know Your Residents (Ms. Francine)

Ms. Francine: very social, “Life of the SNF party”

ENT referred her for an instrumental swallow assessment d/t presbyphonia

Hospital SLP did the study and called to say they were putting a feeding tube in…

SNF SLP opened the chart & shared: Mrs. Francine's living will stated she has no desire for external nutrition and asked her to send her back so she could enjoy her lunch

Mrs. Francine continued to consume a regular diet with thin liquids for years after this study without any respiratory compromise or otherwise noted difficulty swallowing

Renee Kinder, 2016

EX 4: Modify the environment, not the food

(Mr. Charlie)

Dx of chronic COPD he presented with occasional

episodes of severe coughing with intake

Increased spells in the morning accompanied by sputum

when he was moving from laying position during

sleeping to sitting up for the morning meal

DON became increasingly concern with his safety and

ability of the nursing assistants to assist and supervise

Renee Kinder, 2016

Plan for Mr. Charlie

Education was provided to the pt, daughter and nursing team

Why the s/s of coughing or SOB with intake with resp dx

Ex: period of apnea when we swallow where we actually stop

breathing further placing a strain on an already compromised

system for our individuals with CHF & COPD

OT consulted to address reduced positioning

FMP developed, added to care plan, and transitioned to nursing

assistants on best methods for promoting safety during PO intake:

slow rate of intake, alteration of bites & drinks and use of pulse

oximetry to monitor 02 saturations during episodes of SOB

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When the hospital downgrades the

diet (Mr. George) Hospitalization for UTI; downgraded diet to pureed/nectar

CNA reported he was refusing all pureed food & was reluctant to drink the thickened liquids. Family requested diet upgrade

After 2 wks of therapy, he was upgraded to mechanical soft diet

After another 2 wks of therapy, he was safely upgraded to regular liquids

1 year later, he was hospitalized for a mild MI & returned on hospice and with a diet change to nectar thickened liquids

Bedside eval resulted in recommendation of thin liquids with supervision during SLP treatments.

After 2 weeks of therapy, he said he wanted water with all meals and refused thickened liquids

Care plan: his decision was documented and he returned to a regular diet with thin liquids

Resident preference vs. Diet

recommendations (Ms. Mabel)

CVA 1 year prior; hospitalized due to a fall then admitted to a

SNF on pureed/nectar

Oral phase dysphagia resulted in recommendation of pureed

diet

Pharyngeal phase dysphagia resulted in recommendation of

nectar-thick liquids

Through gestures & a wipe-off board she shared that she refused

her thickened liquids and that she wanted regular food

Agreement to short-term compromise

(Ms. Mabel)

Ms. Mabel’s positive prognostic factors included:

Significant increase in strength

Very slow & careful with eating; take all the precautions

Excellent comprehension of directions and memory of

learned strategies

Determined to eat and drink whatever she wanted

• After bedside evaluation, she was upgraded to a mechanical

soft/nectar

• Bargained to work intensely and then get another MBSS done

• After 3 weeks, MBSS completed; upgraded back to thin liquids

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Documenting the Resident’s

Preference

Example note of informed consent

“Per bedside swallow evaluation Mr. Jones is at high risk for

aspiration when drinking thin liquids. No overt signs or

symptoms of aspiration or penetration were seen with

nectar thick liquids. Education provided to family and Mr.

Jones regarding risks for aspiration and aspiration

pneumonia. Family reported concern regarding

dehydration, as this was an outcome of a prior instance of

thickened liquids when Mr. Jones refused to drink thickened

liquids. Family does not want to begin a nectar thick liquid

diet. SLP recommends no straws with thin liquids and

aggressive oral care to reduce risk of aspiration. Family

receptive to no straw and oral care recommendations.

Continue skilled SLP services to improve safety with PO

intake and reduce risk for aspiration.”

Document…

“Document status, progress, recommendations, and

responses every day.

“Not only should this hold up better in court than an

instance of education, but it’s an approach that fosters

empowered decision making which respects the elders we

serve.”

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“There is fear of negative outcomes, but

people forget about the negative outcome

of not being allowed to make a choice.”

Elizabeth Thompson Beckley

The ASHA Leader, May 2017

Care Planning and Informed Consent

Care Planning for Resident Choice

Step 1: Identify the Choice

Step 2: Discuss the Options

Step 3: Determine how to Honor the Choice

Step 4: Care Plan the Choice

Step 5: Monitor and Make Revisions

Step 6: Quality Assurance and Performance

Improvement (QAPI)

Source: 2015 The Hulda B. & Maurice L. Rothschild Foundation

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Case Study

Resident demonstrating aspiration of all consistencies due to

hiatal hernia –poor tolerance for more than 2 or 3 bites due to

reflux and aspiration

Resident not agreeable to PEG tube as alternate means of

nutrition, prefers to continue eating and drinking

Care Planning for Resident Choice

STEP 1: Identify and Clarify the Resident’s Choice:

Mr. B wants to have whole pieces of meat

He does not want to drink honey thickened liquids any longer, wants

regular

He wants to have bread

He wants to use straws

Why is this important to Mr. B?

He prefers to bite into meat

Thickened liquids do not quench his thirst or give him enjoyment

He loves bread and likes how it fills him up

Straws help him control the liquids so he doesn’t spill them on himself

What is the Safety Risk / Concern?

Mr. B has daily occurrences of perceived aspiration:

coughing episodes with meals, followed by decreased

respiratory function

Mr. B has experienced aspiration pneumonia in the

past and has instrumental documentation of dysphagia

including silent aspiration and weak esophageal

peristalsis

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STEP 2: Discuss the Choice and Options with the Mr. B

Potential benefits to honoring his choice: Greater satisfaction, higher QOL, greater sense of independence and ability to choose care

Potential risks to honoring resident choice: Higher risk of choking during meals potentially resulting in death; aspirating during all liquid intake which could lead to pneumonia.

What alternative options were discussed?

Alternatives Discussed

Having meat cut into bite sized pieces, rather than whole or

mechanically altered (compromise)

Trial a less viscous texture such as nectar to assess if it is a safer

option than thin, but more tolerable to the resident

Have thin coffee, but other liquids thickened

Ensure oral care is completed at least 2x/day (consider Frazier

Free Water Protocol if successful)

Eating bread under the supervision of staff or family so that he

can get help quickly if a choking incident were to occur

Alternatives Discussed (cont.)

Trialing use of a 2 handled cup or cup with a

spout to aid in liquid transfer without spilling or

using straws

What education about potential consequences of

the choice alternative actions/activities was

provided?

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Alternatives Discussed (cont.)

SLP provided education on risks/benefits in conversation

on 9/14. DON reiterated the risk for choking, potential

to need Heimlich maneuver, and risk for hospitalization

due to aspiration pneumonia, of which Mr. B has a history.

Mr. B stated that he understood the risks “but some things

in life are worth it.” Inactive POA stated that he

understood the importance of Mr. B’s choice and stated,

“If you want to be dumb you have to be tough.”

STEP 3: Determine How to Honor the Choice

Options preferred by Mr. B:

Ensure oral care completed 2x/day with prospect of FFWP

Eating bread under supervision

Trial use of 2 handled cup instead of straw use

Options non-preferred by Mr. B:

oHaving meat cut into bite sized pieces

oTrialing nectar thick liquids as alternative to honey

oHaving regular coffee but other liquids thickened

STEP 4: Care Planning the Choice

What specifics steps will be taken to assure both the

resident and the staff follow the agreed to options?

SLP: Implementation of new diet orders,

communication of new diet with all members of the

care team, monitoring of tolerance of new diet,

training/education of dining safety and compensatory

strategies with resident and staff, research of

mechanical soft snacks and candy that can be purchased

by Mr. B’s family.

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STEP 4: Care Planning the Choice

DON: Monitoring health implications of new diet (respiratory status,

body temp, weight), preparation of acute interventions in the event of

a choking incident, implementation of compensatory strategies,

implementation of oral care to minimize the risk of aspiration

pneumonia

Dietary Manager: implementation of agreed-upon diet,

securing/maintaining spouted cups

Resident: follow through with diet recommendations agreed upon,

compliance with oral care, self monitoring of eating/swallowing

performance and overall health

POA: adherence to agreed-upon recommended diet for snacks

Steps 5 & 6

Step 5: Monitor and Make Revisions: Monitor the progress of the plan and its effects on Mr. B’s wellbeing and ongoing desire to continue with the choice. (1 month after implementation, or in the event of change in health status, then at least quarterly during Care Conferences. ) Then revise the plan as needed and if desired by the Mr. B.

Step 6. Quality Assurance and Performance Improvement (QAPI) The QAPI team should review trends related to Mr. B’s choice and safety, particularly if his requests may have been denied, or when the team may have identified patterns of such care practices that might be improved by performance improvement action plans.

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Better care.

Better patient outcomes.

Better results.

[email protected]