Recommendations v Residents' Decision - a Storm in a Tea Cup?
Published: 17 August 2017
Published: 17 August 2017
I recently wrote in an article - There’s no Place Like Home: Home-Like Environments in Aged Care Facilities - about the dilemmas nurses face when supporting residents' free choice and decision-making when the action they wish to take is contrary to a non-nurse health professional's clinical assessment and recommendations. The main thrust of the article is about being commonsensical in such decisions so that the resident can experience joy in their final years, even if that joy comes with an element of risk.
Over the last few months, I have witnessed three residents being referred to a speech pathologist (SP) for coughing during and/or following drinking or eating. On each occasion, the SP recommended thickened fluids (and a softer diet), which was refused on the first serving or within the first 48 hours.
Frank is a cognisant 96-year-old war veteran of English descent. He fiercely enjoys his cup of hot, sweet white tea for breakfast, lunch and dinner, along with three smokes.
The care staff called me over to him saying he was upset and had refused his food and fluid for all of the morning, and most of the evening before. I found Frank very distressed and he begged of me, “…sister, all I want is a bloody cuppa tea. Not this muck. A man may as well be dead…” The 'muck' he was referring to was a plastic tumbler of thick, caramel coloured, lukewarm fluid. This was an L1 cup of tea.
The outcome for Frank was that he finally got a cup of thin-fluid tea, after 35 minutes of:
Another outcome, however, was that when the visiting SP returned a week later, she was concerned that an RN (me) had overridden her recommendations. The SP's fear was that the RN (me) had increased Frank's risk of aspiration, which she had previously lessened by assessing and formulating recommendations, at yet another RN's request. Her concern, and rightly so, was why make the initial referral in the first place?
Actually, what we have here, is just Frank, who has the right to make informed decisions and indulge in (reasonable) risk-taking.
To guide our support for Frank's case to continue enjoying his regular fluid tea, we nurses considered each of the following:
I am not trying to make this residential aged-care issue into something bigger than Ben Hur, nor am I wanting to trivialise the event as merely 'a storm in a teacup'. But, I believe that some professionals (nurses included) are becoming overly cautious and overly protective -not so much of the resident and their wants, but of their registration. I believe - and I am confident - that following the appropriate guidelines, as mentioned above, acts as my defence against any potential reporting/investigation by AHPRA.
The above is a discussion of how we worked through our situation. It is in no way intended that other aged care facility staff follow suit. You have your own processes to follow. However, what is clear is that making such decisions requires the input of several parties, working together (don’t forget the resident!), and with reference to relevant guiding documents, including your facility's policies.
Christine (RN, BN, MPHC) is an RN with 40 years experience, traversing the profession as an AIN, EN, RN, RM N.ED. to DON. She is currently in transition-to-retirement and working as a casual RN on the floor in a small rural hospital with an aged care facility attached. Her interests are aged care and particularly nurses; their working relationships, team dynamics and how nurse leaders and managers deal with the day to day complexities of leading and managing. See Educator Profile