facility responsibility to the obese

[onthemark]

In my LTC facility, there are a few woman (in their 50's and 60's) who weigh over 400 lbs. Despite their morbid obesity, they eat as much as they want including desserts, and also order take-out food! Doesn't the facility have a responsibility to monitor and curb their intake just as they do with diabetics? What do you think?

[SkaterGurl]

People make poor dietary choices because: it's easier, it's cheaper, it's what they've always chosen, they don't know any better, it tastes better, everybody else is eating it, etc.

You can educate them, provide them with substitute choices that taste just as good as the bad food they are eating (but is this a reality?), show them how much healthier they would be by eating healthier (but you are up against the curve-at 400+ pounds and older, as most people have a fatalistic attitude "I've got to die of something, so I'll just eat what I want until then" type of attitude.

[leslie :-D]

If a resident lives in a LTC facility receiving public benefits to pay for medically necessary care, is it not possible to dismiss the resident for gross failure to comply with a reasonable treatment plan?

People lose their Medicare benefits if they refuse to participate in PT, OT, ST, etc. How is this different?

Shouldn't scarce beds be used for the treatment of patients who are willing to make an effort to comply with the treatment needed to improve their health?

i was reading over one version of the pt bill of rights...

and in it, under Consumer Responsibilities, it partially states:

"In a healthcare system that protects consumer or patients' rights, patients should expect to take on some responsibilities to get well and/or stay well (for instance, exercising and not using tobacco)..."

it's too bad there's no culpability on the pt's part, because as it stands, i don't think we're doing them any favors.

http://www.cancer.org/Treatment/FindingandPayingforTreatment/UnderstandingFinancialandLegalMatters/patients-bill-of-rights

leslie

[brandy1017, ASN, RN]

I would be most concerned that the facility has working lift equipment to move these patients safely and not be injured! That is the most important thing in my book.

Sad to say, but in my experience the grossly overweight patients are on antipsyche meds and that seems to be a major culprit in massive weight gain. Patients that are 300+ are usually on antipsychotics and I think if they were off these their weight would go down or at least stabilize. The pharmaceutical companies aren't satisfied that people with schizophrenia are on these, they are putting out commercials to get more average people with depression to take them as well. I think the risks of antipsychotics outweight any benefit for depression and should be strictly limited to the truly psychotic patient!

[CapeCodMermaid, RN]

Jolie, You may think it's a reasonable treatment plan, but people still have the right to make bad choices for themselves. It little matters who is paying the bill.

I've had several very very heavy people in my facilities. The cost is sometimes too high for us....bariatric equipment isn't cheap. I've rarely known gross obesity to to caused by antipsychotic medications.

[Jolie, BSN]

I guess I just don't understand the difference.

Hubby's elderly aunt was in a skilled facility post hip fracture. She was terribly depressed and her pain was not properly managed. She refused to participate in PT due to these factors, and was notified by Medicare that her stay would no longer be funded. She had X number of days to move out or arrange to be self pay. I realize that her Medicare in general was not cancelled and she did have coverage for other health needs.

However, I don't understand how her refusal to participate in PT was any different than the diabetic patient next door who circumvented her treatment plan (she was there for wound care) by eating any and everything she chose, without regard to her meal plan and whose stay continued to be funded.

[onthemark]

Thanks to all of you who replied. I understand how we cannot enforce a diet plan just as with a diabetic. However, I believe that when any patient is receiving services at taxpayer expense they need to be held accountable and should help with the treatment plan. I appreciate Leslie (above) bringing to our attention the Patient's bill of rights. Here is the full paragraph that Leslie referred to:

Consumer responsibilities

In a health care system that protects consumer or patients' rights, patients should expect to take on some responsibilities to get well and/or stay well (for instance, exercising and not using tobacco). Patients are expected to do things like treat health care workers and other patients with respect, try to pay their medical bills, and follow the rules and benefits of their health plan coverage. Having patients involved in their care increases the chance of the best possible outcomes and helps support a high quality, cost-conscious health care system.

Like another writer above, I wonder what would happen to these patients if they didn't have our nursing care, but it only seems fair to me that these patients should comply with the treatment plan especially when it's at taxpayer expense. It's a tough dilemna and I wish I knew what the answer was.

[xtxrn, ASN, RN]

It may be fair, but enforcing it would be a logistical nightmare, with thousands of handicapped and physically ill people dying in the streets. Literally.

It's also their home. It's not punishment. "Complying" generally refers to following the basic facility rules --no open flames, no food in the rooms without proper storage (had several with small frig's- not those on restricted diets- but that was because their FAMILY intervened where the facility couldn't...no smoking unless in allowed area (residents have to be provided that) etc.

I understand what you're saying... but not all are on Medicaid. So then the private pays can kill themselves and it's ok? Remember, the govt made the rules. That should explain a lot.

Facilities have their own list of patient rules...they're not federally standardized- so again, no say with Medicaid.

People have the right to destructive behaviors. Should they be put on the street for not following something they didn't agree to? (probably - but this is the real world). It's a problem....and ombudsmen and families can help. But if the state comes in- they want to see the non-compliance on the care plan, that the MD has been notified, and documented teaching ....and verbalization that they understand the risks. Money isn't going to be looked at.

Should the smokers, tobacco chewers, those who refuse minimum hygiene, etc also be kicked to the curb? It's not just dietary issues that can be brought into this.

[xtxrn, ASN, RN]

I guess I just don't understand the difference.

Hubby's elderly aunt was in a skilled facility post hip fracture. She was terribly depressed and her pain was not properly managed. She refused to participate in PT due to these factors, and was notified by Medicare that her stay would no longer be funded. She had X number of days to move out or arrange to be self pay. I realize that her Medicare in general was not cancelled and she did have coverage for other health needs.

However, I don't understand how her refusal to participate in PT was any different than the diabetic patient next door who circumvented her treatment plan (she was there for wound care) by eating any and everything she chose, without regard to her meal plan and whose stay continued to be funded.

The difference is that Medicare has to see progress in therapy... they stop paying for THAT. She doesn't lose her Medicare benefits. The therapy notes have to document progress- no participation= no progress, so it's fraud on the part of the facility to keep her on Medicare. The diabetic can still get the wound care, regardless of her diet..YES- she should comply...but it's not what is looked at re: reimbursement. $$$$$ calls the shots.

Medicaid and private pay (everybody is assuming that all non-compliant people are Medicaid :)) are "maintenance" residents. There are care plans, but no determination of how the facility is paid based on their progress like with Medicare. Major difference. Medicaid is a flat rate determined on income. Medicare is based on skill level and progress. Two totally different billing systems.

[caliotter3]

Even with diabetics the patients have a right to eat whatever they want. All we can do is educate and give appropriate diets. If they order takeout its on them.

When I was a new CNA in a LTC facility, I asked one of the nurses why a diabetic was going to town eating goodies brought in from home. I didn't think it made sense. I was told at that time about the fact that patients have the right to do what they wanted, even if it meant a bad time for everyone all the way around. That lesson stuck with me all these years, even though it doesn't necessarily make much more sense today than it did then.

[xtxrn, ASN, RN]

I would be most concerned that the facility has working lift equipment to move these patients safely and not be injured! That is the most important thing in my book.

Sad to say, but in my experience the grossly overweight patients are on antipsyche meds and that seems to be a major culprit in massive weight gain. Patients that are 300+ are usually on antipsychotics and I think if they were off these their weight would go down or at least stabilize. The pharmaceutical companies aren't satisfied that people with schizophrenia are on these, they are putting out commercials to get more average people with depression to take them as well. I think the risks of antipsychotics outweight any benefit for depression and should be strictly limited to the truly psychotic patient!

Not to mention that many neuro disorders can cause the patient to have NO sense of being satiated. They're always hungry. THere were locks on the refrigerator and cupboards at the head injury place I worked at. Cardiac, psych, hormone, and other meds cause weight gain. That's also got to be considered.

There are parameters re: weight gain with the quarterly MDS/care plans.....and on any Medicare PPS patient.

[caliotter3]

I sometimes wonder about my present eating habits. It would be interesting to find out the real root cause of my inability to stop ingesting more than I need. I have noticed a distinct difference in the urge to eat from what I experienced in my youth, when I considered myself to be normal. Would not be very surprised to find out that there is a neurological basis.

[xtxrn, ASN, RN]

I sometimes wonder about my present eating habits. It would be interesting to find out the real root cause of my inability to stop ingesting more than I need. I have noticed a distinct difference in the urge to eat from what I experienced in my youth, when I considered myself to be normal. Would not be very surprised to find out that there is a neurological basis.

One never knows. Eating and overeating (and compulsive undereating- a sort of subclinical anorexia) can be related to neurotransmitter changes. Also, after meeting my bio-mom this last spring, we both eat "normally" (she actually eats approx 1/2 of a 'normal' portion (as decided upon on the nutritional label)- we're both overweight and have battled for years- often with starvation in the mix- which just kicks in the survival mode to hoard calories for self-preservation- eat normally again, and it packs weight on faster.

Any whack on the head, CVA, or other head injury? Might be a good idea to see about a work up- it's not out of the question :) :hug: