Dietitians: Who better to Advocate for Residents’ Self-Determination?

As you set the New Dining Practice Standards in place, you learn you must know the resident really well to truly honor her right to choice and autonomy – that a bowl of rice is not just a bowl of rice for “Mrs. Chu,” the subject of my last post.  She’s told you her entire rice ritual including her favorite type of grain, cooking method, accompanying condiments, and way to have it served … all down to the traditional china bowl.

Now, who is going to ensure she actually receives rice the way she has always enjoyed it?  Will it be the physician? The nurse? Speech pathologist? Therapist?

No, none of the above. We dietitians and our professional organizations, in my opinion, must educate all these other professionals and advocate for residents’ right to nutritional self-determination.

The New Dining Practice Standards resulted from a process initiated five years ago by CMS and the Pioneer Network.  Introduced for surveyor and practitioner training and implementation in 2011, the new standards are endorsed by eleven professional, standard-setting organizations, including the Academy of Nutrition and Dietetics (formerly the American Dietetic Association).

Yet despite the wide breadth of credentialed support for the new standards, a distressing number of care providers still seem largely unaware of them. Education and advocacy is clearly needed if the new standards are ever to have the intended impact on improving residents’ quality of life.  Dietitians are in the best position to meet that need on a person-to-person basis.  Academy of Nutrition and Dietetics members must lead in promoting the new standards on the national level.

Dietitians have long played a vital role by assessing dietary needs and making professional recommendations.  We really are the appropriate professionals to educate residents and their families on the benefits of various nutrition therapies.

But once we have made our assessments and recommendations, dietitians need to give equal support and energy to assisting residents in following their own chosen course of action.  We must accept that a comfort care plan with foods and fluids of choice and no hospitalization may be the resident’s preferred outcome, or that refusing nectar thick liquids in spite of the potential increased risk of choking is a resident choice to be honored by the facility.

Before moving from his private home into long-term care, an elder with diabetes may have long ignored the doctor’s advice to eat less salt and lose weight – it is a patient’s right to refuse medical advice.  And if, as a resident, he continues refusing dietary recommendations that again is his right supported by F151.  To that end, dietitians must step back and let the decision default to the residents.   We also must educate our interdisciplinary team (IDT) and together advocate aggressively for resident directed goals, approaches and outcomes.

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As dietitians, we have a professional code of ethics that bounds us to work with residents to support autonomy and self-determination, and now we have the New Dining Practice Standards detailing how to do that.  We must defend our professional standard of practice to advocate for our residents’ freedom to choose as fiercely as we exercise our professional standards for implementation of the Nutrition Care Process.

We can begin on the organizational level by educating all professional staff, including physicians, nurses, CNAs, speech-language professionals, pharmacists and others on the new standards.  The white papers upon which the new standards are based are authored by medical directors, physicians, a gerontological psychologist, dietitians, nurses, a pharmacist and others.  The papers are available for reference on the Pioneer Network website.

Remember that the New Dining Practice Standards reference several universal recommended courses of practice, including:

  • Diet is determined with the person, not exclusively by diagnosis.
  • Assess the person’s condition; assess and provide the person’s preferred context and environment for meals, in other words, the person’s preferences, patterns and routines… and personal meaning/value of the dining experience.
  • Include quality of life markers such as satisfaction with food, service received during meals, level of control and independence.
  • Unless a medical condition warrants a restricted diet, consider beginning with a regular diet and monitoring.
  • Empower and honor the person first, whole interdisciplinary team second, to look at concerns and create effective solutions.
  • Support self-direction and individualize the plan of care.
  • When one makes risky decisions, plan of care will be adjusted to honor informed choice, provide support to mitigate risks.
  • Most professional codes of ethics require professionals to support the person in making their own decisions.
  • When caring for frail elders there is often no clear right answer.  Possible interventions often have the potential to both help and harm the elder.  This is why the physician must explain the risks and benefits to both the resident and the IDT.  The information should be discussed among team members and the resident/family.  The resident then has the right to make his/her informed choice even if it is not to follow recommended medical advice and the team supports the person and his/her decision, mitigating risks by offering support.
  • All decisions default to the person.

CMS support for implementing the New Dining Standards was clarified in a March 1, 2013 email to survey agencies and providers.  As dietitians, ours is clearly the appropriate profession to advocate for adoption of the standards to increase our residents’ quality of life while in our care.

Linda Bump, MPH is a Registered Dietitian and Licensed Nursing Home Administrator with a passion for resident choice and quality of life with a particular focus on the kitchen as the heart of the home.  As an administrator, she has guided four organizations through transformations to a social model of care.  She has extensive experience as a consultant on the Household Model and has provided education on culture change to 60+ nursing homes through her work with Action Pact since 1999.

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