Cheri L. Elson and Allen G. Drescher, Retired
21 S. 2nd St. ● Ashland ● Oregon ● 97520
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The Culture of Care

The signs of a good nursing home include treating the underlying medical problems, relieving pain, and doing everything possible for the residents to feel comfortable and at peace.  Psychoactive drugs should always be the last resort for treating the symptoms of dementia and there are many steps a care facility can take before resorting to medication.

Enlightened care providers are increasingly turning to “comfort care” to enhance the quality of life for their residents. This approach, as its name suggests, focuses on keeping the residents comfortable using a nurturing, individualized approach looking at the emotional, social, and spiritual needs of their residents, as well as the medical ones.  The goal is to keep residents comfortable, thereby avoiding unnecessary drugs. This can be done through a variety of means:

  • knowing the residents well enough that basic needs are never a major issue, and needs can be anticipated
  • embracing a philosophy of individualized care
  • adjusting the manner and pace of interacting with the residents to be more suitable for the needs of those living with dementia
  • recognizing and treating pain aggressively
  • treating family and friends as the true partners in care that they are

The simplest of issues may trigger conflict: an incompatible roommate, room temperature issues, unenjoyable music choices, a loud television.  Someone living with dementia may not be able to effectively communicate what is bothering them and it is up to the care providers to be patient and understanding in discovering the root of the issue.  Common symptoms of dementia, such as restlessness, pacing, and repeated questions, should be both anticipated and accepted.

Individualized care and more attention are some of the best substitutes for drugs.  As your loved one’s advocate, insist on a customized care plan which takes into account personal sleeping and eating schedules, bathing methods, and other services which will keep your loved one happy and comfortable.  A facility which takes the time to really learn about their residents, their history and life’s journey, will be more likely to meet these needs effectively.

Nursing homes can also stop unnecessary drugging by improving staff training on how to respond to symptoms of dementia.  Talk to the facility where your loved one lives and ask if they have the local Alzheimer’s Association chapter conduct training for their staff.  There are also certified coaches in Teepa Snow’s “Positive Approach to Care” who can provide valuable training for both independent and facility-based care partners.  If on-going training is not part of their protocol, urge them to make it so.

It takes a village to be a care partner to someone living with dementia.  Finding a residential facility able and willing to truly be part of that village will help ensure there is no unnecessary medicating and that your loved one will have the best life possible until the very end.

Advance Directives and POLSTs

I am often asked the difference between an Advance Directive for Health Care (ADHC) and a Portable Order for Life-Sustaining Treatment (POLST).  While both address end-of-life decisions, they do so in different ways.

An ADHC is a legal document in which a person states what health care measures they want if they are unable to communicate on their own.  An ADHC names a health care representative to speak to and direct the physicians in the place of the person creating the document.  In Oregon, we are mandated to use a specific form, which is basic to say the least.  However, we may supplement it so that it speaks to our personal desires and concerns.  ADHCs do not require a doctor or an attorney; it must be either notarized or witnessed by two adults, neither of whom are named as health care agents.  It may be changed or revoked at any time.  Everyone over age 18 should have an ADHC and they should be reviewed annually to ensure they remain current with one’s end-of-life decisions.

A POLST is a medical order completed with one’s primary care provider.  POLSTs address emergency situations in which a person may not be breathing or have no pulse, and both hospital personnel and EMTs will follow them in an emergency.  A POLST must be signed by a Health Care Professional (defined in the POLST itself) to be valid.  POLSTs can also become part of the Oregon POLST registry, allowing the medical orders in it to be accessed quickly in an emergency.  Typically, a POLST is completed by someone who is seriously ill or frail and toward the end of life.

Here is a table which sets out the differences between an ADHC and a POLST:

Advance Directive
A Voluntary Legal Document

A Voluntary Medical Order

For all adults regardless of health status at any age

For those with advanced illness, or frailty, or a limited prognosis at any age, depending on health status

1) Appoints a legal decision-maker
2) Memorializes values and preferences
3) Is signed by the patient

Is a specific medical order and is signed by a Health Care Professional

Provide for theoretical situations in which a person may not have capacity for decision making

Provides for likely events that can be foreseen

Guidelines for imagined future situations which may arise and for which a person may have preference for a particular kind of care plan

Specific medical orders addressing defined medical interventions for situations that are likely to arise given the patient’s health status and prognosis

Both documents are important and have a place in an overall estate plan.  Conversations with one’s medical and legal professionals will ensure that the appropriate documents are in place and end-of-life decisions are known and honored.

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