Safety of care
Long-term care: Quality decisions
Originally published June 2014
With an aging population and an increased focus on long-term care, more physicians will find themselves caring for patients in long-term care facilities. Doctors working in this setting bring a special blend of care, comfort, and compassion. As physicians may face unique issues when caring for residents of long-term care facilities, being aware of risks will prove beneficial to the provision of safe care.
Communication and collaboration in long-term care settings
Long-term care facilities, also known as residential care homes or nursing homes, are settings in which communications with residents, residents' representatives, and other health providers are of utmost importance. Residents may need special consideration when it comes to communication, most often because of their age or health status. Doctors will want to tailor the pace of their conversation according to the needs of the resident, use easily understood language and other communication tools, and check for apparent understanding.
Physicians will likely have to navigate communications with family members (sometimes several of them) or substitute decision-makers. Family members may be easily available, or in a different geographical location making communication more challenging. In all cases, doctors should use plain language, provide sufficient detail, and encourage questions and involvement in care planning. Doctors should also document all patient care discussions in the patient record.
A review of the CMPA cases involving care provided in long-term care facilities over a 5-year period (2008–2012) found that communication issues between the physician and the resident, or the resident's family, was the most common medico-legal risk. Other risks were related to deficient evaluations, communication problems between the physician and other healthcare professionals, documentation, and resident monitoring.
Communication and coordination of care between all providers are critical elements of healthcare delivery in long-term care settings. Healthcare professionals, including nurses, provide most of the care. Physicians need to collaborate, communicate clearly, and be attentive to information being provided by all caregivers, whether face-to-face, in writing, or by telephone. Timely follow-up of test results and effective patient handovers between doctors in long-term care settings is also necessary for safe care.
The CMPA believes clear responsibilities and accountabilities among professionals in a collaborative care team are essential to promote patient safety, reduce risks, and assure the continuum of care. A well-written medical record is useful in communicating information among team members, and documenting residents' care and any transfer of care, and serves as a record for consideration should problems arise in the future. Team members need to agree on their roles and responsibilities. Doctors should always be mindful of the facility's policies and procedures for collaborative team functioning.
Long-term care facility regulations
Long-term care facilities are licensed by provincial and territorial governments, and they must comply with specific regulations. These regulations generally outline the responsibilities of healthcare providers. For example, a physician may act as a medical officer for the facility, or as an attending physician for a patient residing in the facility.
While it is the facility's responsibility to comply with licensing requirements and other standards, doctors working in long-term care facilities should be aware of provincial and territorial standards designed to protect the rights of residents. Some provinces and territories have enacted legislation that establishes, or requires that facilities establish a bill of rights for residents. The intention is to make sure long-term care facilities are truly homes for the people who live in them. Residents' rights put residents in charge of their care, and help to ensure they are treated with respect.
Furthermore, while the obligations and expectations vary by jurisdiction, physicians should be aware of their roles and responsibilities regarding the prevention of abuse of residents in long-term care homes. For example, the legislation in some jurisdictions requires physicians and individuals to report when they have reasonable grounds to suspect that a resident of a long-term care home is being, or is likely to be, abused or neglected. Abuse may be broadly defined to include suspected misuse or misappropriation of a resident's money by the facility operators. In some cases, the physician may be obliged to take reasonable steps to protect a patient from abuse or neglect.
Complex issues in long-term care
Physicians working in long-term care contend with important and complex issues, including quality of life, medical management (including often limited mobility), decision-making and patient autonomy, mental health, artificial nutrition and hydration, and advance care planning.2
Most long-term care residents take several medications. This can pose significant risk. Physicians should be particularly vigilant about medication prescription and administration, medication side effects and drug interactions, and the monitoring and evaluation of residents. Doctors should complete a resident assessment before prescribing a new medication, and ensure there is a current and complete medication list on the resident's health record. To the extent possible, doctors should also provide long-term care residents (or their families) with information about their medication prescriptions and answer all relevant questions.
Decision-making and consent
Consent to treatment in long-term care is just as relevant as in other healthcare settings. With few exceptions, physicians must obtain valid consent before treatment is administered or stopped. Obtaining consent from residents in long-term care may be challenging due to issues such as cognitive impairment and dementia. Consent can also be complicated when family members disagree with the patient, or with each other.
When discussing care plans or treatments, it is important to communicate clearly and check for understanding. Residents and families or substitute decision-makers need time to ask questions. Doctors should be careful about accepting waivers from residents and should seek to engage them in decisions related to their health and care.
Legislation in most provinces and territories provides a means to obtain substitute consent when a resident is incapable of giving valid consent. Substitute decision-makers are expected to act in compliance with any prior expressed wishes of the resident or in accordance with the best interests of the resident if there were no prior expressed wishes.
Advance directives are particularly relevant in long-term care settings. Ideally, residents have clearly outlined their wishes for care and treatment, and these are known to all healthcare providers and family members.
If advance directives are not available, physicians should attempt to talk to residents about the medical treatment they desire in the event they become incapable of making such decisions. These discussions should be voluntary, and centred on individuals' values and beliefs. Doctors should communicate effectively and openly with residents, and if appropriate, family members. Physicians will want to be familiar with and follow any relevant legislation and regulatory authority (College) policies regarding end-of-life care and the withholding of life-saving treatment. As well, documenting discussions and decisions in the medical record is important. Physicians may also consult with colleagues for support regarding end-of-life care.
Risk management considerations
Recognizing the complexity of care required for many long-term care residents, the following risk management considerations are offered:
- Actively communicate with residents, and when appropriate with family members, regarding the resident's treatment plan and medications.
- Return calls from family members.
- Engage with all members of the care team, and promote the effective exchange of information.
- Participate in care conferences to keep lines of communication open and to discuss care options. Care conferences are particularly important in cases of deteriorating resident health or disruptive behaviour.
- Ensure ongoing monitoring of medications, including therapeutic drug levels.
- When there are questions about the treatment plan or medications, follow up with other relevant physicians (e.g. previous family physician) or facilities (e.g. previous acute care setting).
- Arrange for on-call coverage when unavailable. Arrange for timely referrals and transfers.
- Document every resident encounter, especially when there is a change in the clinical condition or treatment plan.
Members are encouraged to contact the CMPA when they need risk management or medico-legal advice arising from the increasingly complex issues related to long-term care.
- The College of Family Physicians of Canada, Canadian Medical Association, The Royal College of Physicians and Surgeons of Canada. 2013 National Physician Survey. Retrieved on November 1 2013 from http://nationalphysiciansurvey.ca/wp-content/uploads/2013/08/2013-National-EN-Q17a.pdf
- University of Toronto. Curriculum: Ethical issues in geriatrics and long-term care. Retrieved on October 31 2013 from http://www.utoronto.ca/pgme/documents/curricula/geriatric_curriculum.pdf