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Editors
Special Issues in Long-Term Care of Elderly Persons in Assisted Living Facilities
Essentials
- Many residents of assisted living facilities have a memory disorder or some other long-term illness that leads to death, and many of the residents are living the last years of their lives. From the viewpoint of functional capacity, not all residents have significant potential to recover if struck by a severe illness. The share of residents having that potential depends on the profile of the facility and its residents.
- A primary task of a doctor working in an assisted living facility is to outline the individual resident's prognosis and make decisions accordingly.
- A decision not to attempt resuscitation and other treatment limitations must be made by an experienced doctor, and grounds for the decisions must be carefully recorded.
Characteristics of residents in assisted living
- The most common underlying conditions are:
- advanced memory disorders
- cardiovascular diseases, including cerebrovascular disturbances
- diabetes
- a recent history of a fractured hip
- psychiatric conditions or syndromes, not related to memory impairment.
- Typical characteristics of residents' health status include
- chronic health problems that become acute
- infectious diseases, such as pneumonia, pyelonephritis and diarrhoeas of varying aetiologies
- mildness of the symptoms of severe illnesses and multiple symptoms of long-term illnesses that per se are not too serious
- polypharmacy.
- Typical characteristics of residents' functional capacity include
- at least moderate impairment of cognition
- reduced ability to cope with all or nearly all daily activities
- symptoms of depression-anxiety
- behavioural symptoms at least in one out of three residents (may vary depending on location and facility)
- shortage of social resources
- pain.
- General principles for choosing treatments
- Non-progressive conditions that have long prognosis are treated as outlined in the article Reviewing an elderly patient's medications Reviewing an Elderly Patient's Medications.
- Preventive medications, that do not provide benefit in short term are discontinued.
- Management of symptoms that cause suffering, such as pain, vertigo/dizziness, constipation and anguish or anxiety, is essential. The adverse effects of drugs may also play a role in these symptoms. Their non-pharmacological management by experienced personnel may also be successful.
- Indications of psychoactive drugs are re-evaluated and if hypnotics, antipsychotic drugs and tranquillisers are found unnecessary, they are discontinued tapering down the dosage.
- In case of palliative and terminal care, special attention should be placed on the indications of drugs.
Listening to the resident's wishes
- The resident has a legal right to refuse offered treatment.
- A spouse or close relative will play a significant role in expressing the resident's wishes when the resident is not able to do so himself/herself.
- The doctor's duty is to ensure that the spouse and close relatives understand that they are not to express their own wishes but those of the resident.
- It is also possible for the resident to delegate a relative or significant other to act for them (continuing power of attorney or acting as a guardian).
- It is noteworthy that residents may be able to express their wishes even when they are no longer able, for example, to manage their financial affairs.
- All expressions of wish of a resident should be recorded.
- It is the responsibility of the attending doctor to attempt to understand what is the true meaning of the resident's wish and to ensure that the resident, and his/her representative, has understood what observing the wish means in practice.
- The doctor makes decisions having the resident's best interest at heart whilst taking into account the resident's wishes.
Treatment guided by prognosis
- The prognosis must be discussed sensitively and tactfully with the resident and/or a dedicated close relative.
- A physician should assess the resident's resources regarding his/her potential to become rehabilitated and whether the disease is progressive. If the disease is deemed to be progressive, the resident's closeness to the end of his/her life must be estimated.
- The resident has the right to be informed of matters relating to him/her and in some cases the right to remain uninformed. The cognition of residents in assisted living facilities is often insufficient to comprehend the concept of prognosis.
- Residents with a progressive disease moving into an assisted living facility may be in the need of palliative care and some of them in the need of terminal care.
- The life expectancy of residents admitted due to psychiatric illness, brain injury or following trauma may be up to 10 years, and even in the end stages of memory disorders the life expectancy may in some cases be several years.
Treatment limitations
- A decision not to resuscitate (DNAR, Do Not Attempt Resuscitation, or DNR, Do Not Resuscitate) or attempt pacing in the event of cardiac arrest is appropriate when requested by the patient or when the patient's prognosis is very poor from the medical viewpoint. The treatment may also be outlined in a broader sense by recording "Allow Natural Death" (AND).
- Other treatment limitations may include e.g. limitations concerning the administration of nutrition and intravenous or other invasive treatment.
- As life nears its end, the resident's resources to withstand treatment measures reduce, whereby limitations are added gradually.
- An experienced doctor must make the decisions regarding treatment limitations.
- The grounds for the decisions, their extent, the identity of persons involved in the decision making (the patient or his/her representative, nurse, doctor) and the date must be carefully recorded.
- Should the patient's condition improve against expectations, the decisions should be cancelled.
- None of the limitations should mean withdrawing treatment in case of an acute illness or distressing symptoms, such as pain, or e.g. leaving a fractured hip untreated.
Enabling reconditioning
- It is possible to attempt reconditioning even in a assisted living facility. This can be achieved by improving the patient's nutritional state, stabilising or treating debilitating physical illnesses and optimising drug therapy.
- Avoidance of leaving the resident to bed also enhances the chances of reconditioning.
- The doctor's role is to assess whether the diagnoses made correspond with the clinical presentation. If there is a discrepancy, something has been missed.
Doctor to provide support for the staff and resident's family
- The staff of an assisted living facility require a doctor's support when major decisions need to be made and when dealing with the residents' relatives.
- The doctor should familiarise himself/herself thoroughly with each resident's case and take part in care meetings when the resident is first admitted in order to promote mutual understanding and the feeling of safety during the last few years of an old person's life.
References
- Alanen HM. Antipsychotic use among older persons in long-term institutional and home care [doctoral thesis]. Acta Universitatis Tamperensis; 1275. Tampere 2007. http://urn.fi/urn:isbn:978-951-44-7138-4
- Brännström M, Fürst CJ, Tishelman C et al. Effectiveness of the Liverpool care pathway for the dying in residential care homes: An exploratory, controlled before-and-after study. Palliat Med 2016;30(1):54-63. [PubMed]