Person-Directed Dining: Don’t Let Fear Keep You From Providing Choice

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By Diane Hall, RD, LD, NHA, President, Balanced Senior Nutrition and author of The Inside Scoop on Informed Choice: A Step-by-Step Guide for Individualizing Diets.

Mrs. Callan (in future, Mrs. C) pushed her plate away. Enough was enough. She wasn’t going to take it anymore. She called the dining manager over and told her she wasn’t going to eat this food – ever again. She was tired of being served endless scoops of pureed food that she could not identify. She wanted a change and she wanted it NOW.

Sound familiar? Welcome to the new world of person-directed dining — and isn’t it about time? For far too long we have accepted the status quo of diet restrictions without questioning their effectiveness among the senior populations. As those of you involved in Pioneer Network know, a lot of the conventional thinking regarding the efficacy of dietary restrictions is just plain outdated. The latest evidence-based research in the New Dining Standards from the Pioneer Network shows that many of these restrictions are unnecessary, or even harmful, to Elders in long-term care communities.  Now, let’s go back to our scenario with Mrs. C and her desire to change her diet.

In her care plan meeting, Mrs. C strongly reiterated that she wanted to eat more of a regular diet even though she had swallowing issues that presented certain risks, according to her doctor. The care plan team knew their job was to work with Mrs. C to come up with a plan of care that honored her choice for a regular diet. They also knew Mrs. C would have to be informed about the specific risks and benefits of a more liberal diet as well as the risks and benefits of staying on an altered consistency diet. Someone would have to gather and share this information so Mrs. C could fully understand it. Documentation would be needed to support the team’s efforts to be sure that she understood the risks, benefits and alternatives on both sides of her decision. Since this was a risky decision Mrs. C was making, the care plan team became overwhelmed and the documentation required seemed daunting. So, that’s how the medical director became involved. They asked him for guidance on the best practices for care planning informed choices. Unfortunately, this only postponed Mrs. C’s care planning.

Don’t let this happen to you. Be prepared!  Don’t let the fear of citations and liability stop you from finding ways to support resident choice., Recognizing that a process is needed in order to assure that the resident, as well as the care team, has the information needed to make an informed decision.  Proper documentation to support the liberalization of his or her diet restrictions is very important.

In order to make person-directed dining a reality in your community, you need to know that:

“More and more, state legislatures and courts are formally allowing the intro­duction of evidence-based clinical practice guidelines (CPG) as proof of the applicable standard of care to which a defendant provider should be held ac­countable in a civil lawsuit. In effect, when residents decide to forgo restricted diets, providers who comply with the clinical practice guidelines may find such CPG’s a “safe harbor” against civil litigation. And because more and more legis­latures and courts are allowing the introduction of this evidence, a lot of negli­gence claims against health care providers aren’t being filed.” Marshall Kapp, JD, MPH, Nursing Home Culture Change: Legal Apprehensions and Concerns.

The answer lies in the process. Perhaps you already have one.  If so, be sure the team knows how to apply it and consider including it in a QAPI project so you can ensure it is working.  If you don’t have a process, a great resource to consult is A Process for Care Planning for Resident Choice, developed by the Rothschild Person-Centered Care Planning Task Force.  This free tool offers a step-by-step process to support residents to make fully informed choices that may be perceived as risky and the care community to document the process behind those choices.  For more detail specific to supporting the choices associated with food and dining, my book The Inside Scoop on Informed Choice: A Step-by-Step Guide for Individualizing Diets is available from the Pioneer Network bookstore.

Making our own choices when it comes to food is something we have all done since our earliest childhood memories.  Don’t let that stop just because someone is living in your nursing home.  Continue to honor your residents’ choice and bring the joy back to eating for everyone in your community.