Family Councils Network 4, 7th Annual Fall Forum
The 7th Annual Fall Form was held Wednesday, October 11, 2017 at the Royal Botanical Gardens. This year’s workshop addressed the complex topic of Breaking Barriers of Communication. Participants came from Burlington, Niagara, Welland, Hamilton, London, Cambridge, Brantford, Six Nations Reserve, and Simcoe.
During the morning session, a diverse panel offered expertise from the view point of Administration, Management, Nursing, Personal Support Workers (PSW) and Families to stimulate discussion and problem solving in communication issues that Long Term Care homes face daily. The panelists, Dr. Marie Savundranayagam, Gerontologist, shared the current research in Person Centred Care, where training PSWs to personalize communication has had a positive result with residents; Heather Neiser, Personal Support Worker, shared viewpoints of how Barriers of Communication with families, co-workers and management affected their work and health; Joanne Cartmer, shared how important listening to all sides of an issue from her experiences as Director of Programme and Support Services; Jim Lamont, shared his personal journey as a Family Member and Chair of a Family Council and Kate MacDonald, Administrator, presented information pertaining to how important proper communication and maintaining lines of communication are instrumental in reducing miscommunication and keeping front line staff, management, families and residents happy. David Montgomery, who was the moderator for the Family Councils Forum, 7th Annual Fall Forum for the third year, kept the event interactive and added some insightful comments.
In the afternoon session, six Scenarios of common communication challenges were tackled in a round table format. Administrators, managers, care-givers and family members worked together to determine the root cause of barriers of communication and offered suggestions for improvement.
I would like to thank all of the panelists, the moderator and the Family Councils Forums Team: Carol Dueck, Recording Secretary; Carol Adamson, Treasurer; Henry Rapzcewicz, Registration and Claudine Van-Every Albert, Programmes/Printing for making this event happen and running smoothly.
Thank you to the Multi-Service Providers: Seniors for Seniors, Hausers Home Health Care; Banyan,
GrocerEase; Connect Hearing; Bay Gardens Funeral Home; and the Network 4 Long Term Care
Advocacy Committee for providing valuable information to the attendees. Thank you to Terri Jenner
and staff of the Royal Botanical Gardens for the wonderful venue and great food. Sponsors for
this event were Shoppers Drug Store, Mohawk Road West, Hamilton; Swiss Chalet, Upper James Street,
Hamilton; Seniors for Seniors, Parkdale Ave. , Hamilton, Ontario and Hausers Home Health Care,
Dunnville and The Albert Group of Six Nations Reserve.
Family Councils Forum, 7th Annual Fall Forum
David Montgomery Kate MacDonald Heather Neiser Joanne Caratmer Dr.Marie Savundranayagam Jim Lamont
Family Councils 7th Annual Fall Forum 2017
"Breaking Barriers of Communication Between Residents, Family and Staff"
at the Royal Botanical Gardens, Burlington
Wednesday, October 11, 2017
8:30 am - 4:30 pm
PLEASE FILL OUT ONE FORM FOR EACH REGISTRANT AND PRINT CLEARLY
Registration must be received by September 20, 2017
Family Councils Forums, 7th Annual Fall Forum
Wednesday, October 11, 2017
8:30 am to 4:30 pm
BREAKING BARRIERS OF COMMUNICATION
BETWEEN FAMILY MEMBERS, STAFF & RESIDENTS
First and Last Name: __________________________________________________
City: __________________________________On. Postal Code_________________
Affiliation (Council, Organization, etc.)_______________________________
TO BE USED FOR COMMUNICATION AND UPDATES ONLY
Special Requirements, i.e. dietary, other: _________________________
AMOUNT: $______ Cheque e-transfer Cash
Payable ONLY to Family Councils Forum
$40 per person; including lunch, nutrition breaks & Multi-Service Provider Resource Fair
424 Mohawk Road West
Hamilton, Ontario L9C 1W9
Contact: Helga Henson, Chair at email@example.com or 289-253-8220
Registration Cancellation and Refund
You must contact Family Councils Forums no later than September 28, 2017, to cancel your registration for the Family Councils Forums 7th Annual Fall Forum. For cancellations made by September 28, 2017, your registration fee will be refunded after the FORUM. No refunds will be given for cancellations made after October 1, 2017.
Cancellation requests must identify the registrant’s name, email address and type of payment (cheque# or cash) to firstname.lastname@example.org.
Receipts will be emailed once payment is received. For individuals who do not have email, a receipt will be provided the day of the event.
See Details of the 2016 Fall Forum Below
Presenters At 2016 Fall Forum
The Advocacy Committee of the Family Council Network 4
is pleased to support the Fall Forum 2016
"ENRICHING THE LIVES OF RESIDENTS IN LONG TERM CARE"
that is being organized by the Family Councils Forums group. To register simply click on the Registration Form and copy it to your computer, complete and submit it to Helga Henson as noted on the form. Seating is limited so register early.
Karen Robins, Deb Bryson and Grace Belliveau
See Details of the 2015 Fall Forum Below
Family Council Network 4 Fall Forum 2015
A special Sub-Committee of the Family Councils Network 4 Advocacy Committee will host the 5th Annual Fall Forum, a series first initiated by St. Joseph's Villa, Dundas. Below is a flyer and registration form which will encourage you to join us on October 21st in St. Catharines at Linhaven Home. The topic is Pathways for Resident Emergency Care - a topic unanimously endorsed by our committee as of critical importance.
This is a topic to help family members prepare for an emergency hospital visit by their loved one in long-term care. A morning panel discussion by health care professionals on The Emergency Hospital Visit will be followed in the afternoon with a discussion between a long-term care physician and an attorney/advocate for the elderly on the associated Challenges.
Please take a few minutes to read over the flyer. To register for the Forum right-click on the Registration Form below, copy and paste it into a Word document and print it; complete the form and return to the address shown with your cheque or money order. We urge you to register early to avoid disappointment. For further information, if you require it, contact Helga Henson, Chair at or 289-253-8220.
Emergency Visits to Hospital by Long-Term Care Residents
At a forum in the LHIN 4 Region to discuss this topic on October 21, 2015, the following OUTCOMES emerged as critical requirements to address the present inefficient processes that can weigh heavily on our Ontario Healthcare System. We encourage the LHIN Networks working with the Ministry of Health and Long-Term Care and other stakeholders to address these issues. We are convinced that addressing these recommended changes would improve present practices and result in ways for improved efficiencies and lower costs.
A full and detailed Summary of the Forum is attached for your reference.
We can put you in touch with guest speakers at the forum and/or would be pleased to assist in resolving the issues below.
Family Councils Fall Forums Committee, A Sub-Committee of the Family Councils Network 4 (LHIN 4 Region) Advocacy Committee
BETTER COMMUNICATIONS AND INFORMATION GATHERING are required for all those in the “circle of care”, including healthcare workers, EMS, SDMs, Residents and families.
STANDARDIZED REPORTING: This process should eliminate irrelevant and superfluous information and should be implemented or these issues will continue. The goal is that the most relevant information be communicated at the right time. Right now forms that accompany residents/patients to hospital are individualized, home by home. This slows the process of informing EMS and Hospital Emergency staff quickly so they can treat the resident/patient efficiently. Forms vary from a single page to multiple pages, some are handwritten, and format and content vary widely.
ELECTRONIC RECORD KEEPING: This action can eliminate errors and assist in accurate and consistent information gathering and communications amongst all sectors. All LTC Homes should use the Clinical Connect web-based portal for medical information.
2. ADVANCED CARE-PLANNING (to try to avoid the 911 call)
ADVANCED CARE-PLANNING through enhanced information exchange can be a preventative strategy so that there is less reliance on 911 calls.
USER-FRIENDLY CONSULTATIONS: If medical consultations are scheduled as a preventative measure, then many visits to the Emergency Department can be avoided. Also, ways could be explored to have specialists come into the LTC homes, to lessen the number of trips to hospital.
LTC FULL SCOPE OF PRACTICE: Homes have to ensure they are working to their full scope of practice.3. EDUCATION
CONSENT: More education is needed for healthcare workers, residents, SDMs and family to understand (1) who has consent and (2) the responsibilities of the individual who has the right to give consent including what constitutes consent.
EDUCATION: More education on Dementia care is needed for all those involved.
SUMMARY OF PRESENTATIONS AT THE 5TH ANNUAL FALL FORUM
OCTOBER 21, 2015 LINHAVEN HOME, ST. CATHARINES, ONTARIO
The theme of the Forum was Pathways for Resident Emergency Care with speakers asked to address a scenario wherein a resident slips and falls in the home and the subsequent pathways for diagnosis, treatment, decision-making, roles of various caregivers and family members, etc.
Moderator David Montgomery introduced the day, explaining the theme and introducing the panel.
Cindy Chovance an RN and BPSO Lead, St. Peter’s Residence LTC at Chedoke kicked off the Forum by addressing decision-making around emergency transfers. She reviewed factors involved including:
1. Professional, legislated and organizational requirements
The need to communicate the outcomes of detailed assessments with a physician
The need to communicate with residents, SDM’s (Substitute Decision Makers) and others
The need for documentation that supports current status and care needs
The potential impact of delays on resident outcome and,
The need to receive an informed consent (see Afternoon Session for legal details) for any treatment or change to a plan of care such as a transfer
2. She then explored Informed Consent:
The first step in obtaining informed consent is determining the resident’s (or SDM if Resident not capable) capacity to provide consent by explaining the following:
1.Nature of treatment
2.Expected benefits of the treatment,
3.Material risks of the treatment,
4.Material side effects of the treatment,
5.Alternative courses of action, and
6.Likely consequences of not receiving treatment
3. Next, one has to Determine Capacity
A resident’s capacity to provide consent is determined at the time a treatment or changes to the plan of care is being offered and through an assessment by a health care practitioner of the resident’s ability to appreciate and understand the implications of a decision.
In addition to this, health care professionals are responsible for providing 6 specific pieces of information to residents or SDM(s) (where appropriate) before they can receive a consent from a resident or their SDM (where appropriate)
4. A detailed case study was given to illustrate how the above points would be applied.
Then, Challenging Situations were listed:
5. Situations that can complicate/impact on transfers include:
•The presumption of a resident’s incapacity
The use of Levels of Care forms as Consent
•Questioning decisions to transfer by HCP’s
•Multiple issues occurring in the home simultaneously
•Other circumstances unique to LTC
All of the above have the potential to result in a negative resident outcome
6. Chovance then outlined practices that will support a smooth transition home including:
•Good communication (while resident is in hospital and prior to return)
•The opportunity to prepare for a residents return (equipment, medications, individual care needs that may include additional resources –human and/or material)
•Consistent approaches to providing follow up information
•Informing SDM/Family members of residents return home
•Consistent and legal approaches to managing consent
•Supportive relationships between care settings
7. Her concluding remarks explained how changes in St. Peter’s Residence have improved the outcomes of emergency care.
Improvements that support building on staff knowledge of Health Care Consent
•Admission process. Improved communication with residents and family members to support resident care decisions throughout the residents stay in long term care
•Stronger alignment between nursing practice and all legislated requirements
•Streamlining processes where possible
•Investigating systems that support access to health information between sending and receiving facilities
•Modified Levels of Care forms (enhance conversations/do not replace consent/no longer accompany resident to hospital)
•......and most importantly, a focus on residents as experts for their own lives and decision makers for their care
8. Final advice was that homes continue to support nurses, residents, SDMs, family members
and other health care professionals to build on their understanding of the relationships amongst resident-centred care, health care consent legislation, and improved resident outcomes.
The next speaker was Brent McLeod, Paramedic Supervisor, Research and Community Paramedicine, Hamilton Paramedic Service.
He outlined the issues under the following headings:
Service Overview: Stations
1 Fleet centre
1 Training centre
5 Stations in the core
4 Stations on the Mountain
9 Stations in the periphery
Total of 18 Stations
Long Term Care Homes
28 homes in Hamilton
759 transports in 90 Days
4-5% of all 911 transports in HPS
Past Medical History
Other pertinent info
Knowledgeable staff, family and patients
Complete, accurate, and clear documentation
Reason for 911 call
Education and feedback to paramedics
SPEAKER THREE: THE RN IN HOSPITAL EMERGENCY
The third speaker in the first part of the morning was Sharon Campbell RN, Staff Nurse ER Welland Site, Niagara Health System who outlined in detail what happens when a resident arrives in a hospital Emergency area.
- ER staff would receive an ambulance radio patch. Typical scenario would be coming in with CTAS 2. 80yr old female from LTC had unwitnessed fall on wet floor. Obvious/Not obvious shortening and rotation of left leg. Pain level 8/10. No LOC. Vitals BP 120/70, heart rate 82, respiration 20, oxygen saturation 98% on room air. Expected arrival time 8 minutes.
-The nurse receiving the patch notifies the Charge nurse and coworkers of the status-incoming patient and a patient room location is reserved.
-In preparation, a red slider board is put on the stretcher. Patient on the EMS aluminum scoop stretcher can be placed directly onto slider. The scoop stretcher is collapsible and the patient will have less discomfort being moved for the anticipated x-rays. Patient needs to be on x-ray table as portable x-ray on the stretcher is good for CXR but not for hip/pelvis. EMS frequently has a pillow splinted between the patient’s legs.
CTAS stands for Canadian Triage and Acuity Scale. Ensures that the critically ill or injured receive attention before the less ill or injured patients.
CTAS 1 Resuscitation
CTAS 2 Emergent
CTAS 3 Urgent
CTAS 4 Less urgent
CTAS 5 Non Urgent
-When EMS arrives the goal is to triage within 10-15minutes of arrival. The triage is a critical first look that allows an experienced Registered Nurse to access patient quickly upon arrival and to assess and determine the severity of the presenting complaint which in this case is possible fractured left hip. Every patient is pre-screened for infectious disease. (This includes screening for travelling out of country within last 21 days.) Screened first includes for Febrile Respiratory Illness (cough, cold, fever), diarrhea and vomiting within the last 2 days, and hospital superbugs MRSA/VRE/ESBL. Positive results would indicate contact, droplet, airborne isolation precautions be initiated.
-Triage involves full set vitals, glucometers for diabetics, brief target history of events, medical history and list of medications. (History can be obtained from the transfer sheet and the computerized patient history if past patient). Includes documentation of EMS IV placement and administration of sedation, and documentation that there is an advanced medical directive. Based on parameters of vitals, pain scale, mechanism of injury patient would be assigned CTAS level of 2. The levels assigned are based on the CTAS scale and the addition of the following modifiers:
Vital signs-respiratory distress, low BP, fever, decreased LOC, decreased circulation to the left lower leg. CAP refill less than 2sec (perfusion).
Pain Scale- What is their pain level on scale 1-10? Pain peripheral or central (chest, head, abdomen)? Face Pain Scale option if non-verbal.
Bleeding Disorder-Is the patient on blood thinners? Mechanism Injury-the higher force the more severe the injury
Secondary Modifiers-are they diabetic and have low glucometer? Does the leg appear dislocated (shortening and rotation)?-A screening for High Risk Falls completed. Allergies documented and red band applied if applicable.
Triage Nurse assigns CTAS 2, which is emergent and recommends MD see patient within 15minutes. The condition has a potential to threaten life, limb or function requiring rapid medical intervention and application of medical directives.
-Triage Nurse assigns location and patient would be offloaded to stretcher on red slider board. EMS gives a report to the primary nurse assigned and she has to electronically sign off on that received report.
-Ensure PPE protocols in place, which includes explaining to family/visitors. High Risk Falls sign in place if applicable. Additional signage can include NPO (fasting in case of surgery) and “Do not use left arm for venipuncture” if a dialysis patient.
-Patient would be undressed, possibly clothes cut off and placed in labeled belonging bag. Hospital gown and warm blankets applied. Recommended Primary Nurse would do a more in depth head to toe assessment, which includes palpitation and auscultation within 30 minutes of arrival.
Recommend CTAS 2 patients vitals q15min q1h for stable/critical pt. Then q2h x 4
Nuero- GCS-do they know where they are, what month? Pupils E&RResp-apply oxygen if sat below standards.Cardiac-skin warm to touch, pulse in left foot? CSM (colour, sensation and movement) and pedal pulse on arrival and q2h.
GI-when did they last eat? Vomiting, diarrhea, colostomy?GU-do they wear a brief? Are they a dialysis patient?Muscle/skeletal- shortening and rotation? Put pillow under calf of affected leg.
Skin-signs bruising and abrasions, lacerations from fall? Tetanus status?Mood-tearful, combative, cooperative?
-Medical directives that apply are initiated. Labs CBC, (checking low hgb) chemistry (checking elevated liver or renal functions), coagulants-- are they on blood thinners)? GRPSCRN (ready for transfusion if needed in the OR), ECG and check if any changes.
-Foley catheter for comfort and in addition check for microscopic blood and UTI (fall on flank can bruise kidney)
-Initiate IV if not done by EMS for administration of sedation and hydration
-ER MD orders CXR, pelvis, hip. Sedation ordered which is usually Morphine 5mg or dilaudid 0.5mg-1mg and gravol 50mg IV
-Fracture Hip confirmed on patients return to ER from radiology. ER MDs read their own x-rays.
-ER MD initiates Preoperative Hip Admission Order Set. Orthopedic Surgeon on call paged. If on weekend in Welland rotate call with GNGH.
GNGH orthopedic surgeon called and arrangements would be made to transfer patient to GNGH.
-Order set includes:
Internal Medicine Consult (cardiac, BP issues, blood thinners, diabetic, DNR status). Order octaplex for rapid correction of coagulation factors for pre-op prophylaxis of bleeding. Correct low or high potassium levels
-Prophylaxis antibiotics IV.Cefazolin or Vancomycin (MRSA positive) decreases post op wound infection.
-Nurse does BMRP. Usually nursing home has photocopied MAR. We can call Pharmacy and have faxed. Drug Profiler available for patients over 65 years.
-Orthopedic consult and admission orders. DNR status
_Prepared for OR. Family complete Pre-op Questionnaire
-Denture and hearing aids removed last minute. Labeled cup or preferably given to family
If Combative Patient. Rely on family, volunteer, sedation, soft restraint on wrist to prevent IV from being pulled out.
-NHS Least restraint policy. If initiated flow sheet
Alternate ER pathways if no fracture
-OT/PT /DP assessment and if deemed safe, can be discharged. Involvement Discharge planner to coordinate with Senior Home need for additional care (PSW, physio. Primary nurse should write on the LTC Transfer sheet for all treatments, medications given, discharge diagnosis. Very helpful if photocopies made available of ECG, lab results, x-ray results and the ER front sheet. Helpful when LTC Home Doctor does rounds to see what was done. In addition, call the LTC Unit and give verbal report and expected time of pick up.
OPT arranged. Base quote $126.99 if no oxygen, precautions and under 200lbs.
If not safe for discharge contact Hospitalist re admission.
Patty Welychka, RN program Director, Perioperative Services/Executive Lead, Chief Nursing Officer, Welland, Port Colborne, Douglas Memorial Sites, Niagara Health System presented a commentary on presentations of first three speakers and suggested ideal standards of care.
1. Resident who falls at LTC Home coming to Hospital in an emergency
• Very Stressful for Resident and Family Members
• Usually come by ambulance
• Often it is difficult to get all the RIGHT information in a timely manner
• Most often ends up admitted to hospital
• Delirium and confusion are very common
• Most likely a traumatic visit (i.e.) heart issues, sudden onset of acute illness or a fall (ie) fractured
2. Fractured Hips are a Priority Program
• The Ministry of Health has priority programs centered around fractured hip care in the province
• 282 million dollars in total 1 year costs in Ontario alone
• Quality Based Procedures are a set of clinical guidelines that standardize care across the province
• Orthopaedic Expert Panel was initiated to help guide standards
• National Hip Fracture Tool Kit
• Quality measures are in place that are reported and monitored at multiple levels (locally, regionally and provincially)
• The Niagara Health System has programs and systems in place to ensure guidelines and protocols are being followed and targets are being met
3. Associated Costs of Fractures Hip Care
• Total costs for acute fractured hip - $12,100. 00 for 7 days
• Full costs include nursing, allied health, food, medications, joint replacement costs itself, supplies overhead costs such as support services; i.e. finance, medical records, housekeeping, etc)
4. Volume of Fractured Hips July to June 2014/15
• 505 fractured hip surgeries performed in one year in the NHS (over 6 million dollars) (MINIMUM)
• 128 patients came from Long Term Care Homes
• 77 patients were discharged back to LTC
• 23 patients expired (these patients are already frail so death rate increases)
• Others went to areas (complex care, rehab etc)
• 12 readmissions out of the 505 cases
• Complication of procedure
• Mechanical complications
• We have 13 Orthopaedic Surgeons (SCS, WCG and GNG)
5. Measures that are Monitored
• The time it takes to get to the operating room from the emergency department is monitored (48 hours)
• Evidence shows that this helps improve morbidity and mortality rates
• At minimum 90% should get to the OR at this timeframe
• Death rates after fractured hip surgery are reported
• Length of hospital stay is compared across the province (7.5 days) for the acute phase
• Streaming of patients post operatively (complex care, rehab, LTC, etc.)
• Compliance to use of Clinical Pathways and Order Sets that drive best practice and standardize care
6. How Can We Improve?
• Enhance Partnerships with LTC Facilities (return back as soon as possible)
• Understanding “pre fall” ambulation and status of resident
• Patient and Family education
• Patient Information sheet to be provided on admission
• Patient Pathway that outline plan of care (LHIN initiative)
• Align length of stay with rehab eligibility criteria
• Plan for weekend transfers/admissions to LTC or Rehab
• Ensure weight-bearing orders, pain management orders and follow-up appointments are clearly communicated to receiving facility
• Better understanding for all Staff (delirium prevention and management right in the ED)
• Post-surgery nutrition is a large focus area
7. Next Steps
• Continue to embrace Quality Based Procedure best practices across the province as they provide yearly updates
• Hip fracture quality scorecards for comparison are to be reviewed with associate action plans
• Hold ourselves accountable for meeting our quality metrics
• Continue to Communicate and Partner with LTC and other facilities not only for Hip Fractures but for - ANY OPPORTUNITY FOR IMPROVEMENT (SUCH AS THIS ONE [Fall Forum])
MORNING Q & A SESSION: Family Councils 5th Annual Forum
Moderator: David Montgomery
1) Brent, how do we determine which hospital a patient gets sent to?
- depends on how many patients are in the ER
- sometimes this is overridden by paramedics who will go to the closest hospital
- LTC homes notify family of where patient is going
2) Sharon, describe some obstacles in ER.
- ER environment cannot meet a family’s expectations (noisy, uncomfortable, busy)
- ER is not senior-friendly
- ER does the best they can, and patience in family members goes a long way for hospital staff
- family members to take accountability for the patient’s hearing aid
- family members to bring blankets, slippers, food, soup, support
3) Cindy, How to resolve a disagreement between SDM and a capable resident?
- if a resident is capable, a resident is capable
4) Brent, Explain the difference between ambulance and OPT.
- Paramedics respond to 911 calls
- OPT gets booked on a non-emergency service (appointment)
- OPT workers are not all paramedics
5) Sharon, ER does not always send a report back to LTC, how can we ensure we always get one back?
- this is wrong, the ER nurse should be calling and speaking to someone at LTC
- sometimes nurses (part time, on-call, etc.) are unfamiliar with policies & procedures, so more rigorous education is required
- if you don’t receive this information, call the ER
- supervisor will discipline ER nurses who do not follow procedures
6) Audience, who does not have a loved one in LTC?
- approx. half the room
7) Cindy, does RN or RPN decide whether to send resident to hospital?
- it would be the resident themselves or SDM
- RN or RPN or doctor will perform the assessment to present to the resident/SDM
- who provides the oversight to transfer consent?
- the person who did the assessment
- is there an investigation if there is a poor end result?
- this question was not answered - remarks went off-topic
8) Sharon & Brent, would ER and EMS be willing to work to create a standardized transfer document?
- yes - Brent seems unsure of who to talk to begin developing this
- Sharon believes electronic communications/records can help a lot
- eliminating transfer of information by hand eliminates chances of error
- What do you need in order to standardize this?
- efforts have begun, but have gone by the wayside.
- seems no one has time to formulate this document
- Sharon thinks this could start at the ‘Director of Care’ level
- Renee Guder, Administartor, St. Peter’s LTC Hamilton: this process has been started many times but never really followed through
- the entire healthcare sector must agree and rigorously use whatever is decided upon
- Karen Pow, Administrator, Woodlands of Sunset, Welland: working with electronic systems may help
- everyone wants different information on the form, this has posed a problem in past efforts
9) Sharon & Brent, what kind of training on dementia care is available to EMS and hospital staff?
- Brent: it is touched on in college paramedic program. Not continued in ongoing education. ‘Very little’.
- have to bring in more education on this.
- Sharon: in ER there is training in conflict resolution
- Does anyone go over the risk of anaesthetic affecting memory before surgery?
- Sharon: the physician does.
- Audience 1: has seen the physician not do this.
- would like to see RN or someone ensure the doctor is explaining this.
- Audience 2: this is the anesthesiologist and physician’s job to take the extra 5 mins
10) Cindy, some homes administer IV, why can’t all of them do this?
- most do now as employees are trained to do this.
- because LTC doesn’t do this on a regular basis, employees are not so efficient at doing this as hospital nurses.
11) Brent, why does all the paramedic staff have to stay with the patient in ER?
- it’s a team - don’t want to split them up
- it seems to be a relatively unchallenged operational issue
- some mention of ‘health and safety’ issues (2 people carrying a stretcher)
- if it is clear the patient won’t need to be moved around soon, paramedics may change their formations (1-on-1, etc etc)
- Sharon: government is working toward more ‘offloading nurses’ to relieve EMS quicker after transport
12) Patty, have falls increased since least-restraint policy?
- falls have decreased since least-restraint was implemented
- Sharon: remember that families are able to stay overnight in the hospital - ask
13) Patty, do all hospitals in our LHIN have the same protocols?
- all hospitals in our LHIN have the exact same protocols, all agree on and are measured by the same standards
14) Everyone, what are the issues surrounding informing LTC when a patient is coming back to the home?
- issues arise when shifts change and information is lost/noisy
- Sharon tends to wait until just before they will be returned
- Sharon admits that nurses are bad at informing LTC when patients die or are admitted - and ‘we’ need to be better.
- Patty admits hospitals and LTC need to ‘partner’ and not be adversarial about beds etc.
15) Brent, OPT vehicles are not ideal for returning to LTC, why are they used sometimes when an ambulance is used to take them from LTC to hospital
- funding issue - cost of running the ambulance is much higher than OPT
- maybe LTC homes can provide patient transfer services?
16) Sharon, the impact for a second transfer is negative - what is the chance of travelling orthopedic surgeons?
- Patty: Niagara surgeons are good at regionalizing their service and getting better
17) Brent, is customer service part of EMS training?
- most complaints about EMS are because of attitude
18) Cindy, protocol time wait for physician response within LTC home
- depends on the situation we are dealing with
- usually a quick response
Moderator David Montgomery, President and CEO, Haldimand War Memorial Hospital and Edgewater Gardens LTC outlined the intent of the session, which was to examine the challenges that exist due to a LTC Resident being sent to hospital in an emergency. This session looked at the perspectives of a LTC Physician and a lawyer who advocates of the elderly.
Jane Meadus, Institutional Advocate, Barrister and Solicitor for ACE (Advocacy Centre for the Elderly) spoke on Consent to Treatment in the
• This presentation and any material provided for this presentation is not legal advice but is only legal information for educational purposes
• Legal issues are FACT SPECIFIC and require factual information in order to provide legal advice to resolve an issue/problem/determine your rights
• If you require legal advice, please consult your own lawyer or legal advisor
What is ACE?
• Community Legal Clinic
• Opened in 1984
• Funded by Legal Aid Ontario
• Offers a range of legal services including
– Client advice and representation
– Public Legal Sessions and materials
– Law reform and Community development work
– Legal information and referral
Scope of the HCAA
• Admission to Long-Term Care
• Personal Assistance Services
Defined in the Health Care Consent Act (HCCA) .To review legislation please see:
Key Issues in Consent
• What is Capacity for Treatment?
• How is this capacity determined/ assessed?
• Who assesses this capacity?
• What is Consent and Informed Consent?
• If the patient is not capable who is the patient’s SDM?
• What are the options if there is a conflict about capacity for treatment? About who is the SDM? About whether the SDM is making decisions appropriately?
1. Consent Issues in Transfer to Hospital
• Resident of long-term care home
• Transported by ambulance to hospital for treatment
• What information goes with patient?
• What does the ambulance/Hospital do with that information?
• Who consents to treatment?
• Health Professional (HP) must obtain consent prior to treatment UNLESS emergency
• Consent must be obtained from patient where competent
• Consent must be obtained from SDM if patient not competent
• PIECES OF PAPER ≠ CONSENT
3. Who Consents to Treatment?
• Capable patient
• SDM if patient determined not capable by the HP proposing treatment
• SDMs CANNOT consent for a capable patient EVEN if
– they are named in a power of attorney for personal care OR
– the patient wants them to
• Documents such as “Level of Care”, “Advance Care Plans, “Living Wills” are not in legislation
• ARE NOT CONSENTS
• Only expressions of wishes
• Cannot be completed by SDM
• “Speak” to SDM who must interpret any wishes expressed in them and consent/refuse consent accordingly
• May provide direction to HP in an emergency situation only
5. Mental Capacity
• Mental Capacity: socio-legal construct, meaning varies over time and across jurisdictions
• Assessment/Evaluation: refers to a legal assessment not a clinical assessment
• Clinical Assessments: underlie diagnosis, treatment recommendations and identify or mobilize social supports
• Legal assessments: remove person’s right to make autonomous decisions in specified areas
• Not the score on the MMSE MOCA or any other test
• Not a Diagnosis
6. Presumption of Capacity
• Person presumed to be capable for treatment
– HP entitled to rely on presumption unless there are reasonable grounds to believe the other person is incapable in respect to treatment
7. Definition of Capacity
• Ability to:
– Understand the information that is relevant to making a decision about the treatment, AND
– Appreciate the reasonable foreseeable consequences of a decision or lack of decision.
8. Who Assesses Capacity?
• HP proposing the treatment assesses capacity
• One HP can determine capacity to a plan of treatment IF they have the knowledge necessary to get informed consent
• NOT a psychiatrist or capacity assessor
9. Rights Information
• HP must provide rights information to the incapable person per their professional guidelines
• Generally, that:
– They have been found incapable
– They can challenge finding of incapacity
– If they do nothing, that their SDM will make decision on their behalf
– Provide assistance to apply to CCB (Compliance Certification Board) where patient unhappy with finding
• May be to one treatment or to a number of specific treatments or
• May be to a “Plan of Treatment”
– Developed by one or more HPs
– Deals with one or more health problems that a person has or may have based on current condition
– Provides for administration of various treatments/course of treatments or withholding/withdrawal of treatment in light of person’s current health condition
11. What is Valid consent?
• Consent must:
– relate to treatment
– be informed
– be given voluntarily
– not have been obtained through misrepresentation or fraud
12. What is Informed consent?
• Person must receive information about:
– nature of treatment,
– expected benefits,
– material risks,
– material side effects,
– alternative courses of action, and
– likely consequences of not receiving treatment concerning the proposed treatment that the reasonable person would require to make decisions.
• Person must receive responses to further questions they may have about these matters.
13. Heirarchy of SDMs (Substitute Decision Makers)
• Guardian of person with authority for treatment
• Attorney in attorney for personal care with authority for treatment.
• Representative appointed by CCB.
• Spouse or partner
• Child or parent or Children’s Aid
• Parent with right of access only
• Brother or sister
• Any other relative.
14. PGT (Public Guardian and Trustee) SDM of Last Resort
• PGT is SDM if:
– No person meets requirements, OR
– Conflict between persons in same category who cannot agree and claim to be SDM above others
15. Requirements of SDM
• SDM may give or refuse consent only if he or she is:
– capable with respect to treatment
– 16 unless parent of incapable person
– no court order or separation agreement prohibiting access to incapable person or giving or refusing consent on his or her behalf
– is available, and
– willing to assume responsibility of giving or refusing consent.
16. Ranking of SDMs
• Person lower on list may give consent only if no person higher meets requirements.
– Family member present or contacted may consent or refuse consent if he or she believes:
• no person higher or in same paragraph exists, OR
• if person higher exists, person is not guardian of person, POAPC (Power of Attorney for Personal Care),
Board appointed representative with authority to consent and would not object to him or her making the decision.
• married to each other; or
• living in a conjugal relationship outside marriage and,
– have cohabited for at least one year, or
– are together the parents of a child, or
– have together entered into a cohabitation agreement under s. 53 of the Family Law Act
• Not spouses if living separate and apart as a result of a breakdown of their relationship
Partner and Relative
– have lived for at least one year, and
– have a close personal relationship that is of primary importance in both person’s lives
– related by blood, marriage or adoption
• Is available if it is possible, within a time that is reasonable in the circumstances, to communicate with the person and obtain a consent or refusal
17. What Can SDMs Do?
• SDMs can only consent or refuse consent to treatments and cannot Advance Care Plan
• Sign an “Advance Care Directive”
• “Level of Care Document
• Consent/Refuse consent to a treatment plan
18. How Do SDMs Make Their Decisions?
• SDMs must follow the wishes of a patient applicable to the circumstances if known
• If no wishes are known then the SDM makes decisions in the “best interests” of the patient.
• While capable, person may express wishes
• Manner of expression of wishes - in POAPC, in form prescribed by regulations, in any other written form, orally, in any other manner
• Later wishes expressed while capable prevail over earlier wishes.
• Wishes are directions to the SDM who must determine if they are applicable to the decision to be made
• Wishes are NOT CONSENTS
• Health practitioners always must get consent from a PERSON except in an emergency
20. Best Interest
• SDM must consider:
• values and beliefs
• other wishes expressed while incapable
• whether treatment is likely to:
• improve condition
• prevent condition from deteriorating
• reduce the extent or rate of deterioration
• whether condition likely to improve or remain the same or deteriorate without the treatment
• if benefit outweighs risks
• whether less restrictive or less intrusive treatment as beneficial as treatment proposed
21. Transportation to Hospital
• As much information about the patient’s ongoing care as possible should go to the hospital with the patient
• Often will include:
– “DNR Confirmation Form”
– “Advance Care Plan”
– “Level of Care Directive”
– “Living Will”
• THESE ARE NOT CONSENTS
22. DNR Confirmation Form
• EMS workers are not HPs
• They cannot use clinical judgement
• Are required to treat and resuscitate
• EXCEPTION is if this document is provided
• Must be part of the Plan of Care and Consented to by patient or SDM
• Patient/SDM can always revoke
23. DNR Confirmation Forms
• Are NOT:
– “Do Not Treat” forms
– “Do Not Transfer” forms
• Only relate to Emergency Responders not having to provide certain specified procedures
24. Emergency Treatment
• In an EMERGENCY, HPs can treat without consent in very limited circumstances
• The treatment is limited to only what is necessary to deal with the emergency
• Definition of emergency:
• If person is apparently experiencing severe suffering or is at risk, if the treatment is not administered promptly, of sustaining serious bodily harm.
HCCA s. 25(1)
• Incapable Patient
• Can be administered without consent where the HP proposing treatment believes that:
– There is an emergency
– Delay required to obtain consent would prolong suffering the patient is currently experiencing or will put patient at risk of sustaining bodily harm
• Capable Patient
• Can be administered without consent where the HP proposing treatment believes that:
There is an emergency
– Consent cannot be obtained due to a language barrier or disability
– Reasonable steps have been taken to communicate but no means found
– Delay required to obtain consent would prolong suffering the patient is currently experiencing or will put patient at risk of sustaining bodily harm
– No reason to believe the patient does not want the treatment
25. Parameters of Emergency Treatment
• Treatment can only continue for as long as reasonably necessary to find SDM/practical means of communication in order to obtain informed consent
• HP must comply with any known competent wish of patient
• HP may also treat despite refusal of SDM if they believe:
– it is an emergency AND
– SDM not complying with s. 21 of the HCCA
26. Other Issues
• Neither LTC or Retirement Home residents can be discharged to ER/Hospital
– LTCHs must meet criteria to discharge set out in the LTCHA and Regs.
– RHs are tenancies and they do not “discharge” – require eviction
• Does not necessarily mean that the person SHOULD go back
• Hospital/HPs still owe patient duty of care
• If coming from home – safety also an issue when deciding to admit
Dr. Kanwal Shankardass, Family Physician, Medical Director, St. Peter’s Residence LTC and Associate Clinical Professor, Family Medicine, McMaster University,
Three Steps to a Successful Transfer
• Starts from the time of admission
• Information gathering – on admission, during the stay and at the time of transfer
• Communicating the information from the resident, family and staff
• By effective team work
1. Information Gathering
• At the time of admission
- from CCAC – medical not adequate
FP/Specialists – not available
Resident (70% cognitively impaired)
Families/SDM/POA – at conference for MD
• Information required
- functional status, medical history,
medications, ACP/living will/directives/
• During stay and keeping info current
acute care/specialist visits
admission, annual and ad hoc conferences
Communicating the Information
• How? - verbally, charting and EMR
• Who? - resident/family and staff
- between staff
- between staff and MD/NP/pharmacy/specialists
- between staff and paramedics/ER/acute care
• Transfer forms to clinics/ER
• Annual Health Review Form
• Not in silos
• Team members include resident, family/POA/SDM, MD nursing, NP, SW, pharmacy and overseen by administration
• Keep each other informed at appropriate times
• Physician totally dependant on staff and family to convey accurate information about an intervention in a cognitively impaired resident
• Present CCAC medical form not adequate for medical information
• MD to be present at admission conference. Opportunity to gather medical information
• Team members to be present at all conferences, including family/POA/SDM, MD, nursing/PSW, SW, recreationist, PT
• Regular medication review by MD and pharmacist
• Concise and all-inclusive Annual Health form
• An appropriate Transfer Form which should include reason for transfer, diagnoses, medications, functional status and ACP
Afternoon Panel Session: Challenges Moderator: David Montgomery
With Jane Meadus & Dr. Kanwal Shankardass
19) Jane, what happens if someone cannot speak/hear and wants to use an interpreter to speak on their behalf?
- it is best to rely on family to interpret
- up to the HP to decide whether or not they’re receiving good information
- is the interpreter doing an accurate job of interpreting?
20) Dr. Shankardass, would it be helpful to have Family Council people sit on certain physician committees etc?
21) Jane, if POA is unavailable during transport, who can make a decision for them in the hospital?
- anyone can advocate
- the POA has to make the decision though. If they are truly unavailable, you go to the next person down the list
22) Dr. Shankardass, thoughts on traditional/natural methods of LTC?
- not sure, there isn’t much evidence of these methods being effective
- main thing is the patient should not participate in harmful practices
- Jane: each LTC home must have a policy on the administration of traditional medicines
23) Jane, how to fix a lack of communication with the physician?
- if the resident is competent, there is no requirement of communication with the family (no legal requirement)
- if the resident is not capable, the physician is bound by law to get consent from the family
24) Dr. Shankardass, how do you feel about family conferences without family members?
- admission conference should have family member there.
- otherwise, if the resident is competent, it’s not necessary, but it is good to have family there
25) Jane, does LTC policy override LTC act?
26) Dr. Shankardass, will we ever see a paperless process from LTC to ER to Hospital and back again?
- this is ‘my’ wish, we just need to get everyone on the same page.
- we need to make this a priority
27) Jane, if the LTC act overrides LTC policy, why do LTC homes write policies?
- Governments pass an act with certain stipulations
- Home policy must support and complement, not override the stipulations set out in the act
- Are LTC policies available to families?
- if they pertain to the families, then yes
28) Both, who has final say regarding medication changes for a resident after hospital?
- generally physicians follow the prescription set out by acute care
- if there are new medications though, the Home physician must deal with these & family
29) Dr. Shankardass, who is responsible to contact POA about new/different medications?
- often the nurse/RPN will obtain consent for the physician
- Law says it is up to HP to ensure informed consent is obtained
30) Jane, what rights to family members/POAs have regarding medications, restraints, etc.?
- are you the substitute? Yes - rights. No - no rights - rights go to substitute.
- these decisions must be made from HP offers.
- substitutes cannot demand treatment
31) Jane, if last resort is Public Guardian, how hard is it to reverse this?
- not hard because Public Guardian doesn’t generally want to be the authority, they try to find an alternative
32) Dr. Shankardass, Among all healthcare levels, would standardization not be better coming from Ministry of Health?
- Dr. Shankardass: with the bureaucracy of that, it will never move
22) Jane, is there a policy in place when Public Guardian requests access to nursing reports?
- information in a health record is owned by a patient
- the paper is owned by the hospital
- governed by Personal Health Information Act
- very specific process to achieve access to this information
- there is a form that is very specific to LTC Homes
- to see and review them: you can request and get them for/in 30 days
- if it’s for treatment: that information should be provided quicker
- if they won’t provide information, you can appeal that
p) Dr. Shankardass, why are there different DNR levels at different LTC Homes
- Jane: shouldn’t have any
- these are not legal, they are often misused
q) Dr. Shankardass, what is best way for staff to determine if a resident cannot hear or understand?
- talk louder
- get hearing tests to determine whether or not they can hear at all
r) Jane, any litigation happened because of LTC transfer to Hospital and has that changed policy?
- nothing specific
- this kind of litigation tends to get settled so there isn’t much case law with seniors
- litigation with seniors is quite hit or miss - not much case law
s) Jane, when a parent with severe dementia cannot be left alone in the community & is on the list for CCAC but does not want to go - who has consent? Alone the individual would be in danger.
- resident will need to be evaluated with regards to capacity
- substitute probably does not have the authority to force them and LTC Home does not have the authority to detain them
- practically, it tends to get forced through, but legally, it’s usually not legal
- best would be to have the individual appeal to capacity board if the individual is very unwilling
t) Both, if DNR is not legal why use it at all?
- Dr. Shankardass: it’s a guide for now
- Jane: it’s a wish by the resident
u) Jane, is there a law that protects seniors?
- Substitute Decisions Act protects adults who are not capable
- Problem is not necessarily the legislation, it’s the implementation of it
- maybe it’s not very good to over-protect
COMMENTARY BY MODERATOR DAVID MONTGOMERY
The day ended with a brief commentary or overview of the day’s theme “Pathways for Resident Emergency Care”.
A video of the full commentary is available. Click here.
Key Issues that Emerged:
Understanding and applying the rules of consent for an emergency trip to hospital and subsequent treatment
There is a wide variability in the format of the transfer form and in how information is shared about the resident/patient
Presently paper-based and often handwritten forms are frustrating and cumbersome
At times, insufficient documentation accompanies the resident/patient
At each step—the LTC home, to EMS, to hospital staff-- there is not enough training in dementia care and a lack of funding to address this issue
EMS and Hospital Emergency Departments lack the time to address specific issues of the LTC resident/patient
EMS Hamilton reports only 10% of 911 calls by LTCs are true emergencies
LTC homes complain of poor communication from the hospital staff when resident/patient returned
Sometimes when the resident/patient is returned at a shift change, communications are negatively affected
Risks related to surgery not well communicated to the resident/patient or the SDM and family
Suggested ACTION ITEMS; i.e. Changes and Solutions to the Above Issues
CONSENT: More education is needed for healthcare workers, residents, SDMs and family to understand who has consent and the responsibilities the individual who has the right to give consent
EDUCATION: More education on Dementia care is needed for all those involved
STANDARDIZED REPORTING: This process should eliminate irrelevant information and must be implemented or these issues will continue. Then the right communication at the right time will be the norm.
ELECTRONIC RECORD KEEPING: This action can eliminate errors and assist in good communications amongst all sectors. All LTC Homes should use the Clinical Connect web-based portal for medical information
ADVANCED CARE PLANNING through enhanced information exchange can be a preventative strategy to 911 calls.
BETTER COMMUNICATIONS are required across all sectors involved in this “circle of care”.
LTC FULL SCOPE OF PRACTICE: Homes have to ensure they are working to their full scope of practice
USER-FRIENDLY CONSULTATIONS: If medical consultations are scheduled as a preventative measure, then many visits to the Emergency Department can be avoided. Explore specialists coming into the LTC homes, rather than the other way around
I. A new Ontario Government Regulation as of September 1, 2015 requires that every hospital have a patient relations delegate. By law, feedback can be given to this person in any hospital and they have 5 days to get back to the complainant.
II. Ontario is also recruiting a health ombudsman so that, in the future, there will be visible improvements in patient relations.