Ethics in LTC

In chapter 12 of Long-term Care: Managing Across the Continuum, several ethical issues were mentioned such as emotional impact on consumers, access to care, rationing, “spending down”, patient autonomy, informed consent, end of life issues, and everyday issues including privacy, confidentiality, and restraints.  I think it’s important to touch on each of these issues because ethics in long-term care is an issue that will constantly need to be approached.

First, I want to discuss the emotional impact on consumers. The text states emotional impacts resulting from loosing independence, being separated from loved ones, and the vast change in environment (Pratt, 322-323). When providing care to this fragile population, it is important that we also address their emotional needs and provide support. I couldn’t imagine what it would be like to be separated from a loved one, live in a room with a complete stranger, and need assistance with the most basic daily functions such as dressing, toileting, and eating. When caring for patients in a LTC setting, I think it’s important to think about ourselves in that position and how we’d like to be cared for if it was us.

Next is access to care. We all know that access to any form of care is usually limited by reimbursement. Those with greater ability to pay have better access to care. As the aging population continues to increase, access to LTC will continue to be a problem. We need to start thinking about how we’re going to approach this problem in the upcoming years when the ratio of elderly to workers is 2:1. Somehow, access will need to be increased and the problem of funding this access will also become an issue needing to be addressed.

“Spending down” is another controversial issue. To gain access to public funding, those who previously would not qualify are required to spend down their assets. In the text, this section compares the ideas of elderly being required to use up their assets on paying for their own care, or the right to pass down their life savings and gain public funding although they could pay for themselves (Pratt, 327). This section reflects on a very tough issue. I do feel that the elderly have a right to keep their assets safe and to pass their life savings down to children and grandchildren, but at the same time, funding those that can fund themselves takes funding away from those who have no way to afford healthcare on their own. So the important question I have yet to find an answer to is, how do we decide if they should spend their assets on their own healthcare or provide them funding so they can pass down their assets?

We all demand autonomy when it comes to our healthcare. We all want to be active and involved in making decisions regarding treatment that will affect our lives. However, the elderly is a population that faces limitations to this autonomy. They don’t always have a say or a choice in where their care is provided or who provides this care. Away that we as healthcare providers could maintain the patient’s autonomy is to include them in making certain decisions. For example, when I was in high school and apart of the medical academy, we spent a clinical rotation in a nursing home. I worked in the Alzheimer’s unit. We were taught to always include the resident in the decision making process. For example, asking the resident what they’d like to wear today and allowing them to choose their own clothing allows them to have a say in what goes on. Other ways to include them in their own autonomy is to ask if they’d like a bath before or after breakfast, if they’d like to partake in certain activities, and other simple decision making questions.

Informed consent is an issue that affects every person receiving and providing any type of care. The problem related to LTC is that although you may give your resident all the information they may need, they may not have comprehended all the information you gave.  It is important to give your patients all the information they need to consent to treatments and make informed decisions about their own care. I want to use myself as an example of what happens when you make decisions that you’re not fully informed about. This past year, I found that I had some personal problems with my own health and after undergoing surgery, the next step was to try an experimental drug. Unfortunately, when discussing the drug, I was not made aware of all the possible side effects that I may experience. Had I known what all the risks against benefits were, I most certainly would not have agreed to take the drug. It was in the form of an injection that lasted 3 months. Almost immediately I had terrible side effects that affected how I was able to go about my daily functions. The drug made me feel sicker than I had ever felt and there was no way I would have agreed to it if I had known. Because the drug lasted 3 months, I had no choice but to suck it up and deal with it until the effects wore off. I wish that I was given all the information so that I could have made a decision that was right for me. After that experience, I now know how important informed consent really is.

Another ethical issue is end of life issues. At the end of life, it’s hard to determine the decision-making capacity of the person and if they need to allow family members to make decisions for them.  One way to help with this problem is advanced directives or a living will that states what actions they want to be taken in certain end of life situations (Pratt, 336).  As health care providers, we are all going to face end of life issues that will be very hard on us. It is important to make decisions based on the benefit of the individual patient and what the patient wants for them, not what we feel is right for them. I watched a show the other night about a 13 year old girl with a terminal heart decision who made the decision herself to not have a heart transplant. Although her parents and her healthcare providers all thought that she was making the wrong decision, she was making the right decision for herself based on her own cost-benefit analysis. Although we may not always agree with people’s decisions, as providers, we have to understand that they’re making that decision for themselves and what they feel is right for them.

The last ethical issue I want to touch on is the everyday issues that will be faced in the LTC setting.  Privacy and confidentiality are two main issues that are constantly faced in the LTC setting. I wrote my LTC memo this week based on these two main issues. I feel that it’s extremely important to respect the privacy of every person that we care for. Once again, when approaching these issues, we need to put ourselves in this position and understand how important privacy would be to us. Sometimes, residents are put in somewhat degrading positions such as when being assisted with bathing and toileting. To ensure that residents and patients maintain their dignity, we have to support them mentally and emotionally for them to feel comfortable allowing us to assist them in very vulnerable situations. Handling the patient’s privacy with the utmost respect and professionalism will allow them to understand that we are not here to degrade them, but to provide help and comfort in any situation.

Every ethical issue mentioned in chapter 12 are both important and issues that will frequently be addressed in the LTC setting. To handle them in appropriate manners, we have to put ourselves in their shoes and provide care based on who we’d want to be treated in those situations. Always providing support and care with the utmost respect will help residents for the better in these ethical situations.

Pratt, John R. Long-Term Care Managing Across the Continuum. Third. Sudbury, MA: Jones and Bartlett Publishers, 2010. 321-351. Print.

Joint Commission on Accreditation of Healthcare Organizations

The long-term care industry is regulated through both government agencies and private institutions. One organization that I found interesting during module 4 readings was the Joint Commission on Accreditation of Healthcare Organizations, otherwise known as JCAHO.

JCAHO is an independent, non-profit, organization whose mission is, “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (“Joint Commission”). JCAHO, which was founded in 1951 and began LTC accreditation in 1966, accredits a wide range of LTC organizations such as hospitals, sub acute care units within hospitals, and home healthcare agencies. JCAHO provides “deemed status” to those it accredits which means they are in compliance with Medicare conditions for participation and do not need to be surveyed separately by Medicare (Pratt, 259).

JCAHO is made up of a group of 29 physicians, administrators, nurses, employers, labor representatives, health plan leaders, quality experts, ethicists, consumer advocates, and educators. Participation in accreditation is voluntary and not mandated.  Those wishing to participate in accreditation must write a letter requesting participation and must pay privilege fees (Pratt, 259). JCAHO is focused on quality outcomes and is resident-centered, and performance focused. Today, organizations seek accreditation from JCAHO as proof of their high-quality care.

I think it’s interesting that LTC organizations face both public and private regulatory issues. Out accrediting agencies talked about in chapter 9, I think JCAHO is interesting because it provides accredited organizations with “deemed status”. Thus, these organizations only have to be surveyed by JCAHO to prove their compliance with Medicare standards. Also, it makes sense that organizations would participate in accreditation as a way to prove that they are providing high-quality care.  This shows that they are aware of the importance of regulations in place and are willing to comply to set their level of care to higher standards than the typical organization. If I was in search of a long-term care facility, I would most definitely choose one that is accredited.

"Joint Commission Fact Sheet." The Joint Commission. The Joint Commission, 23 Aug

2010. Web. 4 Nov 2010. <http://www.jointcommission.org/AboutUs/Fact_Sheets/joint_commission_facts.htm

Pratt, John R. Long-Term Care: Managing Across the Continuum. 3rd. Sudbury, MA: Jones and Bartlett, 2010. 259-260. Print.

The Strengths and Weaknesses of the Long-Term Care System

As we’ve read in the textbook, Long-Term Care Across the Continuum by John R. Pratt, the long term care system evolved over a period of time before it came to be what it is now. Up until recently, most families took care of their own members and there was no demand for institutions to provide this service for them. As the times have changed, so has the need for more formal caregivers. Today, the long-term care system is composed of many different levels of care from skilled nursing facilities, and assisted living facilities to home healthcare agencies, and adult day care centers. The long-term care system today, as we know it, consists of many different strengths and weaknesses. Before we could look to improve it at any time in the future, it is important for us to recognize both the strengths and the weaknesses.
The first strength to recognize is that as much as society and the world have changed in the last few years, the long-term care has continued to find ways to meet the needs of its consumers. For example, not only are there skilled nursing facilities, but within them, there are specialized units to meet the needs of its residents such as those with Alzheimer’s, Parkinson’s, and other forms of dementia. When I was in high school, I was fortunate enough to spend some time in the Alzheimer's unit. Within the unit, the resident's received more specialized care and had a better provider to patient ratio.
Another strength, is the development of more innovative types of care including “aging in place”, multi-level facilities, and adult day care centers (Pratt 25-26). For example, “aging in place” is designed to allow residents’ changing needs be met at the same facility. Although the system is not perfect, it still allows residents to receive the care they need in a setting that is both comfortable and safe. Multi-level facilities incorporate many different levels of long term care such as skilled/ non-skilled nursing facilities, assisted living facilities, and other independent or supported lifestyles all in one localized area (Pratt 25-26). This allows residents to move throughout the different levels of the facility as their needs change throughout time. Adult day care centers allow families to take a break by offering a daytime facility for those with long-term needs.

I think the adult day care center is a great idea. Some of the clients that came to the adult day care center that I volunteered at in high school rode a bus over from the nursing home just to spend the day and become involved in more activities that were provided by the day care center. Most residents were the elderly; however some were younger adults who had suffered from head trauma or chronic illnesses. The center was open from 6:00 am- 5:00 pm. Clients were provided breakfast and lunch, as well as 2 other snacks throughout the day. Activities included puzzles, singing, dancing, and crafts. Sometimes, service dogs were brought in to visit with the clients. Informal caregivers were relieved to have a service that could provide the care and allow them to take a break for certain hours of the day.

One of the most important strengths of today’s long-term care system is the effort to become a more integrated health system (Pratt 25-26). The long-term care system provides a holistic level of care to not only meet the medical needs of its residents, but also the spiritual and social needs as well. It offers a vast array of services including support with activities of daily living, feeding, exercise and socialization, medical care with chronic illnesses, nurses, volunteers, and more. Most facilities these days have physical therapists, occupational therapists, transportation, foot doctors and other kinds of specialized services that allow residents to receive care in a localized area. Facilities also may include a series of services in the same place such as assisted living, skilled nursing facility, and a home health care agency.
Although there are many strengths that surround our long-term care system today, there are also a few weaknesses that should be brought to our attention. The main one being the fact that our system is still driven by reimbursements (Pratt 25-26). Most services provided are those that will be reimbursed and it is hard to find services for which there is no reimbursement. The care that many residents receive and where that care is received is sometimes based off third-party payers and not what is best for the residents themselves. To improve the long-term care system, it is important to make decisions based on what is best for the consumers and allowing consumers to decide themselves what is best for them. I think this concept is a bigger problem for those that are on public insurance like Medicare and Medicaid. Patients on certain insurances are sometimes limited to who they can see and what services they can receive. For example, those who use MCO's are given a list of doctors that they can see. To receive coverage, they must go to the doctors used by that MCO. If they use a different doctor, they may receive less coverage or none at all. I think in the future, it will become more and more important for the system to become more consumer-driven.
Another weakness is that the system has a poor reputation. Most have acquired the reputation of being “a place someone goes to die” or “a place to get rid” of someone (Pratt 30). I must admit, I also have the same notion towards nursing homes. Through some of my own experience in both nursing homes and adult day care centers, I’ve seen residents receive inadequate care on occasion and would think twice about placing a family member of mine in a home. To fix the reputation that the LTC system has, I think that facilities should hire more qualified staff or implement programs that provide continuing education on patient’s rights and quality of care.
Finally, because the system is unequal, fragmented, and often uncoordinated, it is not exactly known as a “user friendly” system. Although I have seen the system from an inside point of view, I know nothing about how to understand it from a consumer’s point of view. This could be in part because we never hear much positive things about the system in the media and the lack of information out there.

I do believe that there are many positive aspects about long-term care. It takes a special person to become a long-term care provider. To become a better system, not only for long-term care, but also the health care system as a whole, I believe that it should be more consumer-driven. People should have access to all the information regarding the types of care and should be able to make decision for the benefit of them. After having some experience in both the adult day care level and skilled nursing facilities, I have seen some of the strengths and weaknesses surrounding the system. I believe in the future and with time, the long-term care system will eventually grow to become a more “user friendly” and consumer oriented system and will gain a more positive reputation within society.



Pratt, John R. Long-Term Care Managing Across the Continuum. Third. Sudbury, MA: Jones and Bartlett Publishers, 2010. 24-30. Print.

What Does Long Term Care Mean to Me?

Long term care is based at different types of services that are provided for an array of different people. Such services can include anything from providing medical care such as dispensing medications, providing wound care or physical rehabilitation, to more basic day-to-day care including help with bathing, getting dressed, feeding, and providing emotional support and comfort. It is a level of care that is provided for a lengthy period of time that includes a holistic outlook to meet the physical, mental, and spiritual needs of each patient or resident.



There are a variety of different types of long term care. Majority of these were explained through the Final Horizions, Inc. page on web courses. Some of the more popular types that were listed include nursing homes, adult daycare centers, and home health care agencies. I was lucky to have hands on learning experience in each of these three different long term care categories.



To me, long term care means knowing that the elderly of this society are being taken care of in ways that their own families might not able to. It means that a unique quality of services is being offered to take care of our parents, grandparents, and great grandparents. It means no longer have to worry about whether or not their basic human needs and rights as individuals are being met.



As a provider of long term care, it means that I play a role in bettering the quality of life for these people. I can be both a care taker and a companion and provide not only physical support to assist in daily activities, but mental and spiritual support as well. I can make the difference in someone’s life.



Long term care is an important part of our society because it is always needed, whether it be a nursing home for a parent or grandparent that can no longer independently go about their daily activities to meet their basic needs, or a home health care agency that provides in-house care to those who are not able to commute for healthcare. Our society is constantly growing older and everyone ages. Although today it may be a family member or friend who depends on the services of long term care, tomorrow it could be any of us. Maybe today, long term care may mean a job to help pay my bills and a service that i provide to others, but one day it could mean a service that I rely on to meet the needs I can no longer meet on my own.