Update & Opinion: 

CANHR v. Chapman (Epple, 1418.8) Case, What Should Nursing Homes Do?

California nursing homes, hospitals, and long-term care professionals waited a long time to get the final ruling in the matter of CANHR v. Chapman, which was decided last year.  The judge seemed to be taking longer than expected in issuing the writ, perhaps because he understood its far-reaching implications.  But finally, on February 4, the order was published—and as expected, it will not permit nursing home ethics committees or interdisciplinary teams (IDTs) to consent for antipsychotic drugs or for “withholding or withdrawing” of life-sustaining treatment.  The California Department of Public Health, via the Attorney General’s office, has 61 days from the date this order was released to appeal the decision, if they decide to do so.  CALTCM, along with the California Association of Health Facilities (CAHF) and the California Hospital Association (CHA), will be among the organizations urging CDPH to appeal this ruling, which as written will make it nearly impossible to provide appropriate, compassionate care to the unbefriended incapacitated nursing home resident.

My appointment to chair the Education Subcommittee coincided with my taking on the role of Director of Nursing Home Patient Safety for the Quality Improvement Organization (QIO) that covers our state.  Over the past 8 months I have had to opportunity to travel around the state, meeting with nursing home staff, other stakeholders and developing educational programs.  One of our key efforts is the reduction of antipsychotic medication use.  While we have made significant improvement in California, nearly 1 in 7 long stay residents are still on antipsychotics.  Continued improvement in this and other areas requires a true team approach.  Physicians, nurse practitioners and physician assistants can write orders, but staff must be fully engaged in creating an atmosphere that is conducive to successfully improving the care of residents.

by Timothy Gieseke, MD, CMD                                                             

As of January 1, 2016, CMS is paying for advance care planning discussions.  As a post-acute care specialist with a strong interest in palliative care, I’m pleased that CMS will finally pay for what I have previously done for free (because it was the right thing to do).

This came home to me today as I was seeing a frail quite cognitively impaired 91-year-old man admitted to our facility yesterday.  As I reviewed his digital referring hospital EHR, I was surprised to only find a file indicating DNAR (do not attempt resuscitation), but not a discussion of advance care planning.  Our admitting RN did initiate a POLST conversation yesterday with his DPOA (son), which indicated “attempt CPR.”  As I talked with the son to better understand his dad’s goals and values, it became apparent the son knew his dad had a very limited life expectancy and was OK with DNAR status while at living at his assisted living facility.  However, if his dad were in the acute hospital and had a witnessed cardiac arrest, he believed his father would still want an attempt at CPR.  With this clarification, we completed a POLST indicating DNAR in section A with the son knowing this didn’t apply to the acute hospital setting.  The key issue here is that the POLST was designed for outpatient use and needs to be translated into an acute hospital care plan.  In situations like this,  the blank space in Section B of the POLST can be used to clarify such nuances; for example, “CPR and defibrillation permissible in acute hospital witnessed arrest situation.”

by Jay Luxenberg

Recently, I was invited to participate in a week-long series of events in Taiwan –Aging Innovation Week. While meeting with government officials, it became evident that they are considering adding a Long Term Care insurance benefit to their national health insurance. In recent years I have attended meetings in the Netherlands, Germany, South Korea, Australia and Japan – all countries that offer their citizens a universal long term care benefit.