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Patient Autonomy - How Far Can They Go?
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'Friends with Benefits' in the Nursing Home
A Case Study
by
Steven D. Karnes, MHA (Ferris State University)
Introduction
You are the administrator of an eighty bed nursing facility that is owned and operated by a local conservative church in a small town in Michigan. It is Monday morning and the daughter of one of the residents has just left your office. Her mother's name is Mrs. Vandevort. She came in to talk to you about her mother's relationship with another resident. A male resident (Mr. Kitchens) moved into the facility seven months ago, and Mrs. Vandevort and Mr. Kitchens have become very good friends since then. The daughter is concerned that the relationship has become more than a friendship because staff members reported to her that they found them in an embrace and kissing in a public lounge when they thought that no one else was around. Staff members have also reported to the daughter than when the couple sits together, they hold hands, and there seems to be frequent expression of physical attraction between the two of them. Finally, the daughter has learned, a staff member found Mr. Kitchens with Mrs. Vandervort in her bed. Upon hearing this news, the daughter decided things had gone too far. She said she fears her mother is being coerced into what she called 'immoral activities' by the overly amorous Mr. Kitchens.
Mrs. Vandervort is in the early stages of Alzheimer's disease. She does most of her activities of daily living (ADLs) independently but needs some assistance getting dressed in the morning. She enjoys the activities organized by the facility and is always willing to join in when invited to do so. Mr. Kitchens is a little forgetful but has no diagnosis related to cognition. He moved to the nursing home after a hip replacement. He is a widower with no children, and his nearest relative is a niece who lives in another state. He was living alone in the house where he and his wife had lived for forty years, and he had often stated that he felt quite lonely since his wife's death three years ago. Mr. Kitchens now seems to be increasingly enjoying the community within the nursing home created by other residents and by staff members and he is very involved in activities, even volunteering when needed in various capacities such as setting up chairs for programs, helping transport other residents to activities, etc.
This nursing home facility has a policy that unmarried people cannot share a room, a policy that reflects the values of its owner, a conservative Christian denomination. Although there are currently no policies that specifically address the current issue surrounding the relationship of Mr. Kitchens to Mrs. Vandervort, it is clear from other policies and the mission statement of the organization that a sexual relationship between two unmarried residents would not meet with approval from the facility's board of directors or the majority of its constituents.
As the administrator of this facility, you were aware that Mrs. Vandervort and Mr. Kitchens were friends, but you were not aware of the most recent developments or what the staff had reported to Mrs. Vandervort's daughter until she came to your office to discuss her concerns with you.
You told Mrs. Vandervort's daughter you would get back to her in a few days, hoping this would give you enough time to look at the residents' charts, talk to staff, talk to members of the board of directors, and research rules and regulations pertaining to this situation. You will need to let the daughter know what you have decided to do in response to her concerns about this situation by Friday.
Questions
- What should you, the administrator, say to the daughter at the initial meeting in response to her concerns?
- What steps should you take to investigate the situation?
- What rights do Mrs. Vandervort and Mr. Kitchens have?
- Does the facility have a right to limit sexual activity between residents?
- How do you want your staff to respond to:
- Family members of the residents involved?
- Residents involved?
- Other residents of the facility?
- Administration?
- What should the ethics committee and staff members of this facility do in this situation?
Teaching Notes:
Overview
This problem describes a situation in a nursing home that is not uncommon. The author worked for thirty-three years as the administrator of nine nursing and/or multi-level care facilities and found himself dealing with incidents similar to the example above often. People live in nursing homes and assisted living facilities as well as receive care there. A nursing home is, indeed, the home of the residents who live there, and the community of residents and employees become family in many ways. One of the unique challenges of nursing home administration is managing well in the context of this community. Being a nursing home administrator demands all the skills of managing a health care organization, but it is also a little like being the mayor of a small town where constituents have a strong sense of ownership, residency, and community.
This incident can be used as a discussion of ethics in the long-term care setting. One of the biggest ethical issues facing staff of a nursing home surrounds questions regarding autonomy. When is it appropriate for staff to intervene in the life of a resident or in relationships between residents? Staff members' jobs include protecting the people in their care, but professional care-givers and administrators don't always know where to draw the line between their need to protect residents and the residents' need to make their own decisions, even poor decisions. This incident also raises questions of authority, communication, management, regulations, governance, and public relations.
Research Methods
This incident is based on a number of incidents with which I was involved throughout my career as an administrator and executive director. All of the names in this case study have been changed. Other details have been altered to further protect confidentiality and to enhance discussion.
Learning Objectives
The learning objectives of this case study are for students to:
- Make decisions in response to this situation and discuss the ramifications of those decisions.
- Discover the complexities of working in the long-term care facility environment where people live in close community.
- Analyze the situation from ethical, managerial, and public relations perspectives.
- Evaluate their personal reactions to this incident.
Suggested Answers to Questions
1. What should you, the administrator, say to the daughter at the initial meeting in response to her concerns?
It is important that you do not promise more than you can deliver. Tell her you will do a full investigation and get back to her. Remind the daughter that her mother is still a consenting adult even if she does have mild dementia. Assure her of your facility?s concern to protect her mother from harm.
2. What steps should you take as the administrator to manage and investigate the situation?
Tell key board members about the situation. It is important to keep the board informed. Talk to staff and tell them to refer questions regarding this situation to you. Remind them of the policies of confidentiality. Look in the residents? charts to see what has been charted. This is important to do in order to learn more about the situation but also to make sure the charting is appropriate. Talk to staff members that have been caring for both residents. Find out why they told Mrs. Vandervort?s daughter about their concerns before talking to you.
3. What rights do Mrs. Vandervort and Mr. Kitchens have?
According to state and federal law, residents have the right to privacy, autonomy, and confidentiality. They are entitled to associate and have private communications and consultations with any person of their choice.
4. Does the facility have a right to limit sexual activity among residents?
This issue may be less than clear. Residents do have the right to engage in sexual activity, but the facility has the right to uphold rules of conduct within the community of the nursing facility. One option the facility has is to ask the couple to leave the facility and then assist them in finding a facility that allows sexual activity of unmarried partners. This does not mean, however, that the couple being asked to leave could not bring a grievance against the nursing home and win that grievance. The law is not clear on this issue. The ethical question is: Does the religious community have a right to impose their religious views and conduct on people residing in facilities they own? That is an open question with little history of court decisions and few clear guidelines.
5. How do you want your staff to respond to:
a. Family?
- Keep them informed and refer them to administration on policy questions.
b. Residents involved?
- Respect their rights of autonomy, privacy and confidentiality.
c. Other residents of the facility?
- Listen to their concerns and respond while respecting the privacy of the residents involved.
d. Administration?
- Keep administrators and other supervisors informed. Try to prevent them from being blindsided.
6. What should the ethics committee and staff members of this facility do in this situation?
The role of the ethics committee is to discuss the issues and provide some guidance to the residents, resident?s family and administration as appropriate. It is not their role to make any definitive decisions.
Additional Pedagogical Materials
This case lends itself to small group discussion. One approach is to place students in groups of three or four to discuss the problem, research necessary information, and answer the questions. It is helpful to bring the groups back together as a full class and discuss differences in perception and approaches to handling this situation that may differ among the small groups.
Epilogue
The administrator talked with key board members and then met with the entire board which was divided on what to do. The daughter was unhappy that the facility would not control her mother's and Mr. Kitchen's behavior, but these concerns soon became a moot point as Mrs. Vandervort became ill and the illness had a profound effect on her cognitive abilities. Mr. Kitchens had apparently enjoyed his relationship with Mrs. Vandervort more for the companionship she offered than the physical relationship that had more recently begun developing. When Mrs. Vandervort could no longer converse with Mr. Kitchens, their relationship became more casual, physical intimacy ceased, and the relationship was no longer a concern to the daughter.
Resources
Federal Regulations:
Title 42: Public Health
Part 483: REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES
Subpart B: Requirements for Long Term Care Facilities
483.10 Resident rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights:
(a) Exercise of rights.
(1) The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
(e) Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records.
(1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.
Resources:
Books:
Nursing Home Ethics: Everyday Issues Affecting Residents with Dementia
by Bethel Ann Powers
Journal Articles:
Nursing Leadership (Tor Ont). 2011 Jan;24(4):78-87.
Exploring ethics in practice: creating moral community in healthcare one place at a time.
Scott SL, Marck P, Barton S.
Nursing Ethics. 1996 Sep;3(3):224-35.
Ethics of assisted autonomy in the nursing home: types of assisting among long-term care nurses.
Whitler JM
Journal of Clinical Ethics. 2011 Fall;22(3):212-6.
Incapable sex: a case study.
Everett BJ.
Web site:
American Geriatrics Society: www.americangeriatrics.org
Health in Aging: www.healthinaging.org
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