A resident with dementia who needs end of life care due to pneumonia, COPD, and malignant neoplasm of the left lung has not designated anyone to hold her power of attorney. She has five children, and they cannot agree about the care that is needed for their mother. They want the resident sent to the hospital if her condition worsens, but she just returned from the hospital on comfort care. The resident is eating less than 25% of her meals. The family members do not seem to realize the status of the resident as being end of life, and needing comfort care due to her continued deteriorating status. Facility staff will try to have the family select one person to be the spokesperson for the family. The family has signed a DNR and has agreed to comfort care, but still want the resident transferred to the hospital if any changes occur.
Caring for elders is a complex responsibility. The relationship between the resident and his or her family and between family members may also be complex and create conflict and miscommunication. When this happens, there is a risk the health care team could struggle in identifying and creating a plan to address the resident’s simplest needs, as well as the more complex issues of the resident’s wishes regarding advance directives, palliative care, comfort care, and end of life care. Facility leadership must establish a clear system to identify and follow the known wishes of the resident, whether communicated by the resident or the resident representative, as appropriate. Policies and procedures that identify clear roles and responsibilities should be well-defined for the health care team. The process should begin prior to admission, with the knowledge the health care team gathers from the hospital or community physician, with the resident’s permission. Upon admission, the health care team should clarify the resident’s wishes regarding advanced directives, based on state and federal rules and regulations. Additionally, the health care team should be well trained and confident in discussing advance directives, palliative care, comfort care, and end of life issues with residents and/or the resident representatives.
