Absence of medical care planning

A good friend told me that his father had spent his final days in a nursing home. Not long after he moved in, he had a stroke. In the last period of his life, the man underwent three extensive brain surgeries. His experience was that his father was subjected to unnecessary suffering. They had not been invited to any medical care planning and as far as he knew, neither the relatives nor the father had been asked any questions about their attitude towards this type of intervention.

Medical care planning should be done in conjunction with moving into a nursing home and thereafter annually or when something else occurs that requires a new care plan. The elderly and any relatives participate in the care planning together with doctors and the team, preferably a few weeks after the elderly person has moved in. Then the nurse and the staff get an idea of how the elderly person is doing and what needs the elderly person has. Before the doctor's visit, it is customary for blood samples to be taken if there are no other current test results available. In conjunction with the medical care planning, a medication review is also done. It may then be appropriate to reduce or make changes to the medication. More about medication review in another blog.

Risk assessments for medical care planning

The medical care planning should take place at least once a year. Not infrequently, it needs to be done more often based on changing needs. Many operations have a routine that precedes the planning. It can involve taking samples, symptom rating and inviting relatives so that they can participate in the meeting. Ratings that may be relevant are symptom rating of the type Phase-20, pain rating, dementia rating and risk assessment regarding falls, pressure sores, malnutrition and oral health.

Turning Point Conversations

In the case of permanent deteriorating health conditions, a turning point assessment may be appropriate. This means that the resident, relatives, doctor and nurse agree that the resident should be allowed to pass away peacefully at the facility and not have to be sent to the hospital in case of deterioration.

At a normal-sized nursing home, the doctor may need to manage several care plans for each visit to the nursing home. This is because each one has to go through the annual care planning and those who move in also need to have their review. In addition, a number of residents will need to have a new plan when their health deteriorates. This places great demands on the nurses planning the ward rounds and that there is a clear structure for how the medical care planning should be prepared by different professional groups.

Reflection Questions - Medical Care Planning
Care Staff:
- Are you involved in the preparations for the medical care planning?
- Are the risk assessments brought up in meetings with the team?
- Do you get to know what has been decided in conjunction with the medical care planning?

Manager, nurse, occupational therapist and physiotherapist:
- Do you have a good process for preparing the medical care planning?
- Does every resident have a current medical care plan that is no more than one year old?
- Is everyone on the team involved in the preparations?

Residents and relatives:
- Have you participated in the medical care planning?
- Was the meeting good?
- Are there things that can be improved?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day