Nursing Homes Grapple With Safety vs. Patient Rights

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.

SAN FRANCISCO – Balancing residents’ autonomy with their safety poses constant challenges for nursing homes, particularly when it comes to topics such as sex and administration of antipsychotic drugs, according to several studies in recent years.

"It’s very difficult," said Dr. Melissa L. Martin, medical director of Margaret Tietz Nursing Home and is in the department of medicine at Cornell University, both in New York.

Dr. Martin and two colleagues presented findings from their research on nursing home resident autonomy in the areas of smoking, dysphagia treatments, sexuality, and antipsychotic drugs at the annual conference of the American Society on Aging. They also gave their listeners advice on how to address autonomy vs. safety in these areas.

Smoking

Between 2% and 10% of nursing home residents smoke, Dr. Martin said. She pointed out that, besides its familiar health implications, smoking can accelerate residents’ cognitive decline and risk fires and personal burns.

Quoting from a study by her copresenters – Dr. Paula E. Lester and Dr. Izchak Kohen – Dr. Martin said that 72% of fire-related deaths in nursing homes result from smoking materials (J. Am. Med. Dir. Assoc. 2008;9[3]:201-3).

One way to evaluate a nursing home resident’s ability to smoke safely is to test whether the person can extinguish a cigarette or hot ashes. Both the capacity to recognize the danger and the physical ability to respond are necessary, Dr. Martin said.

A tangle of regulations complicates the issue. Dr. Martin cited the Omnibus Budget Reconciliation Act (OBRA) of 1987, which defined nursing homes as residences where people have the right to smoke. In effect, nursing homes can’t ban smoking for existing residents without losing their eligibility for Medicare and Medicaid funding, she said.

On the other hand, the Centers for Medicare and Medicaid Services says in its regulations that residents may not smoke in their bedrooms unless supervised by staff, and nursing homes must restrict nursing home smoking in compliance with the National Fire Protection Association’s Life Safety Code . Meanwhile, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) has mandated since 1994 that nursing homes discourage smoking and limit it to designated locations, she said.

Under the CMS’s rules, nursing homes can refuse to admit new residents who smoke. "There are a lot of issues with this, too, because it’s very difficult to identify if someone is a nonsmoker," said Dr. Martin. "If they stopped and start again, do they have the right to smoke?"

In an anonymous survey of 248 directors of nursing by Dr. Lester, Dr. Kohen, and their colleagues, 80% of the nurses agreed that residents have the right to smoke. In 86% of the facilities represented in the survey, nursing staff distributed cigarettes. In 68%, smokers had to wear fire-resistant aprons, and in 69% of the homes, there had to be a fire extinguisher in the smoking area. About a third of the nursing homes required a physician’s order to allow a resident to smoke, the nurses reported (Director 2008 Summer;16[3]:37-9,41,43).

Dr. Martin concluded that nursing homes are inconsistent in what they require, but she noted that more and more facilities are becoming smoke free, presumably by admitting only nonsmokers.

Dysphagia

In his presentation, Dr. Lester, associate medical director for palliative care at Highfield Gardens Care Center in Great Neck, N.Y., offered specific recommendations on how balance safety and autonomy in people with dysphagia.

Dr. Lester, who is also an assistant professor at Stony Brook (N.Y.) University, said that while nursing staff may recognize that these residents are better off not eating normal food, family members often don’t. And many visitors bring food that a dysphagic person might choke on.

In a nationwide survey of nursing directors of skilled nursing facilities through the National Association Directors of Nursing Administration/Long-Term Care, Dr. Lester and her associates found that most survey responders thought they had both a right and a responsibility to restrict residents’ access to over-the-counter medications, cigarettes, and alcoholic beverages (J. Am. Med. Dir. Assoc. 2009;10[6]:419-22). But only 17% thought that facilities had a responsibility to restrict access to food, and 24% thought they had a right to do so.

In fact, while only 10% of residents smoke, 97% of nursing homes have smoking policies. By contrast, 40%-60% of residents in nursing homes have dysphagia, but only 37% of facilities have policies on food brought in by visitors, said Dr. Lester.

One solution is to carefully inform family members of the risks posed by food items, then get the family to sign statements of informed consent. "As long as you can document that all the risks have been discussed, I think that’s probably fine," she said. "Maybe this food is dangerous, but for this favorite food, we can make an exception. Or we will say, ‘OK, she can have this food, but only if someone is in the room watching, so if there is aspiration, we will know right away.’ Sometimes we can minimize risk while maximizing quality of life by making little compromises."

Antipsychotics

Dr. Kohenof the department of clinical psychology at Albert Einstein College of Medicine and an attending faculty member at Zucker Hillside Hospital, both in New York, said that about two-thirds of patients in skilled nursing facilities have diagnosable mental disorders, mostly cognitive impairment. Up to 25% have clinically significant depression, 6%-12% have delirium, and 2% have schizophrenia.

In 1986, a study indicated that nursing homes used sedatives and physical restraints on up to 85% of residents, leading to the passage of OBRA 1987, said Dr. Kohen.

Turning to his own research, Dr. Kohen said that the prevalence of antipsychotic use in nursing homes declined after that event and now is 15%-27% (J. Am. Med. Dir. Assoc. 2010 Sept. 30 [Epub ahead of print]).

However, he said other researchers have reported increasing use of antipsychotics since 1999 because of the advent of new medicines with reduced side effects. The Food and Drug Administration reacted against this trend in 2005 with a "black box" warning that elderly patients with dementia are at increased risk of death when they are prescribed antipsychotics.

Citing the NADONA/LTC study, Dr. Kohen said that 64% of nursing homes give antipsychotics only when family members sign consent forms. The study found that 65% of the facilities were using lower doses of antipsychotics since the FDA warning, but only 39% reported a reduced use of antipsychotics overall. Just over half had increased their use of nonpharmacologic interventions, and a similar proportion was using other types of medications, such as anticonvulsants and benzodiazepines.

Other researchers have found that facilities with higher staff-to-resident ratios use less antipsychotic medication, and the same is true of those that educate staff about these issues, said Dr. Kohen. But one or two staff training sessions won’t do the trick, he said. "My concern is that you have a lot of turnover in nursing homes. You have to keep [training] consistently."

Sexuality

The sexuality of nursing home residents presents a different set of challenges, said Dr. Lester. "There is a myth that the elderly are asexual beings." Citing unpublished data from the NADONA/LTC survey, she said that 71% of directors of nursing reported "issues regarding residents’ sexual activities."

Of these, 58% involved residents having sex with other residents, while 22% involved residents having sex with visitors and 60% involved residents masturbating.

The directors were divided on whether nursing homes should allow residents with moderate-to-severe dementia to have sexual relationships. Forty-five percent said yes, 28% said no, and 27% weren’t sure.

A clear majority (83%) said residents’ responsible parties should be notified if a resident with dementia wanted to have sex with another person, while 5% said no, and 12% were unsure.

Only 37% of the facilities had a policy regarding sexual activity, and a similar 35% had a designated space for trysts. Of the facilities with policies, 52% applied these policies to all residents, regardless of mental condition.

Dr. Lester finished by calling on nursing homes to confront the sexuality of their residents more directly. "Sexuality and intimacy needs of nursing home residents are frequently taboo and ignored," she said.

Dr. Kohen, Dr. Lester, and Dr. Martin all reported that they had no financial interests or affiliations that affected their presentations.