living (AL) exists for one very simple reason: most older people don’t want to
live in a nursing home. They want privacy and autonomy, which nursing homes
seldom offer. Despite all the efforts to put the “home” back into nursing
homes, and despite the culture change movement that sought to transform the
structure and organization of nursing facilities, most people still don’t want
to live in a nursing home. One consequence is that assisted living facilities today
are filled with people who not that long ago would have lived in a nursing
home: they are old, they have multiple chronic conditions, and just about half
of them have some degree of dementia. But assisted living facilities were
created with the idea that they would be strictly non-medical residences.
That’s a problem.
tension between the idealized image of the assisted living resident and the
actual assisted living resident increasingly translates into a struggle over
what services AL can legitimately provide and who will regulate them. The rules
are set by the individual states, so what happens in California is not the same
as what happens in Alabama. In some
states, only a licensed nurse can give a patient a medication. In other states,
aides can give out medications. In some states, aides can supervise a patient
taking a medication—they can remind the person he is supposed to take a pill
and watch him doing it, but they can’t take the pill out of a bottle and give
it to him. In other states, aides aren’t even allowed to do that. Periodically,
state legislatures try to change the rules about just how medical AL should be.
That’s what’s happening in Massachusetts today. Proposed
legislation would allow AL to provide certain medical services that are
currently unavailable: treating skin problems, providing wound care, giving
injections, and administering oxygen. And predictably, conflict has erupted
over whether the rules should be changed and if they are, who should be
responsible for ongoing monitoring.
controversy over whether and to how great an extent AL should be able to
provide nursing care is usually framed as a concern about the medicalization of
assisted living. The whole idea of AL is that it is much more like a person’s
home than like a hospital and the concern is that if residents can have medical
procedures on site, this will undermine AL’s home-like essence. But is that
really the way to think about this issue?
all, if an older person lives in his own residence, say the house where he has
lived for the past fifty years, and his spouse gives him his medication, no one
would object that his home has turned into a medical facility. Ditto if a
family member applies skin cream to a rash. And does it turn the home into a
hospital if a personal care attendant wheels in an oxygen tank and hooks it up
to a mask or to nasal prongs worn by the older individual? Family members learn
to give insulin injections. They are taught how to give artificial nutrition
through a gastrostomy tube and to administer intravenous medication. They even
operate all kinds of pumps and monitoring equipment. In fact, the report, Home Alone, issued a few years ago, found that almost half of all family caregivers
reported that medical tasks formed part of their responsibility, including some
pretty complex interventions.
nursing aides aren’t the same as family members. They take on whatever
responsibilities they are assigned because it’s their job, not out of love or
compassion or filial obligation. But the point is that if family members
routinely perform these sorts of duties, in most cases with minimal instruction
and no supervision, then surely aides hired by assisted living facilities could
be expected to do precisely the same things, perhaps with a smidgeon more
instruction and some degree of ongoing supervision. In any case, the act of
putting on a bandage or attaching a bottle of Ensure to a feeding tube doesn’t
automatically turn AL into a medical facility. But failing to letting aides do some of the tasks that people would expect
their families to provide if they lived in their own home turns AL into a very
inadequate sort of a home indeed.
I think we draw the wrong conclusions about who can do what because we assume
that the person who performs a given task should have a thorough understanding
of the technology he or she is using. That would be nice, I suppose, but how many
of us who drive a car have the slightest understanding of how the transmission
works or the difference between a generator and an alternator? In the case of
people taking medicines or getting treatment for a rash, we shouldn’t confuse
administering treatment with monitoring effectiveness. I don’t see why the same
person necessarily has to do both.
ago, I read a study of the use of psychotropic medications in the nursing home.
The authors were shocked to discover that the nurses who gave out powerful
medications had no idea of their side effects and couldn’t identify one if their
life depended on it. I thought at the time and I still think today that the
researchers’ dismay was misplaced. Someone should have been monitoring those
nursing home residents: what was shocking was that nobody was. But did it have
to be the person who doled out pills? Her job was to make sure that Sally Smith
got pills that had been prescribed for Sally Smith—and not pills that had been
prescribed for Stuart Smith. Her job was to make sure that Sally Smith got her
pills three times a day and not twice or four times and that she actually
swallowed the pills. Her job was to report to a physician if Sally Smith became
very sleepy or was more confused that usual or developed difficulty with her
walking—but not to figure out whether the pills were causing those problems.
goes for assisted living today. Of course people should be able to get simple “medical”
treatment on site, just as they would if they had stayed in their previous
home. Of course staff should be able to administer any treatment that family
members routinely provide without an RN or an MD degree. Yes, staff need to
learn how to do these things. And yes, a system needs to be in place to assure
that patients—in this case we are talking about patients—have adequate
monitoring of their medical problems. But let’s separate administration of
treatment from ongoing assessment of the medical response to treatment. And let’s not transform the character of AL by subjecting it to the same rules as a nursing home. The way forward is to provide on site medical treatment while designing new rules that relate separately to the training and supervision of aides who are part of the staff and the provision of ongoing medical care by physicians and nurse practitioners who are not.