Rebecca Ferrini, MD, CMD

Mr. Doe has been in your facility for 3 months, but recently suffered a minor stroke. He is a long-term homeless alcoholic with no known family or friends, and he has also just been diagnosed with diabetes and you need informed consent for treatment. He states that he is fine, doesn't think he has diabetes, and that he wants to go out to get a drink. He says he'll be back before dark.

Can he simply exercise his right to leave grounds and to refuse care? On the one hand, he is "speaking" for himself and there is nobody else to do so, on the other hand, he is pretty impaired and this is a bad decision. You don't have much time to think; the nurse is on the phone now asking you what to do! This case reflects several complex issues, including:

• Balancing the rights of the resident while promoting safety
• Assessing decision-making capacity
• Non-adherence (previously referred to as noncompliance)
• Who is the surrogate for someone who has nobody?

Do you need some quick, practical tools to tackle these problems? Arrange to join your colleagues on Saturday May 12 at the CALTCM annual meeting to learn how to address these complex issues in a way that minimizes risk to the patient, the staff and the facility.

It begins with a capacity assessment took that is quick, and easy to use and remember. We call it "U-CARE" The nurses, social workers or physicians can do a brief, targeted capacity assessment using the acronym U-CARE. Capacity determination involves assessing his Understanding of the situation, the Consistency of his responses and preferences, his ability to Appreciate the probable consequences of his actions and refusal of care, and the Reasoning he employs as he Expresses his opinion. 

If he has capacity, then he is permitted to refuse care and take risks affecting himself, but if he lacks capacity, then what? This session will also familiarize you with the options available for those who have nobody to speak for them. There is a complex web of families, guardians, conservatorships and HSC 1418.8. Not familiar with it? This is a law written especially for SNF residents without capacity and without friends/families. The Health and Safety Code (HSC 1418.8) allows the IDT authority to make medical decisions for residents like Mr. Doe. This session will tell you how to use and document this statute.

It is always challenging when residents don't do what you know they should do. Learn how to enhance adherence and how to reduce risk to the facility from non-adherent behavior, and take home some practical tools. As we never want to be either in the position of violating rights without justification or of being subject to a complaint for neglect (i.e., why didn't you provide care?), or negligence (you let him do what!!??), having a strategy for assessing and addressing Mr. Doe's situation will help us balance these concerns and ideally, to provide the best care possible for him.

This sort of case presents risks no matter what we do. Documenting a reasoned approach that shows an individualized assessment of this resident that balances his capacities, needs and rights to the degree possible, may minimize risks both to ourselves and the resident. Join us in Los Angeles on May 11 & 12 and take home a great toolkit for the residents you serve!