Elderly Care Dilemma (III) : Many obstacles to ‘zero restraints’

As Taiwan's elderly population expands, the role of long-term care and assisted-living facilities is bound to take on greater importance, especially in an environment of limited resources.

With the demand for care bound to skyrocket, some care facility operators are promoting a new trend to help seniors under their care live as independently as possible, including reducing the use of physical restraints on patients who might otherwise harm themselves.

Though the jury is still out on the approach, putting it into practice in Taiwan has faced several obstacles, including legal constraints and difficulties in changing prevailing attitudes in the long-term care sector.

To start with, according to Kao Hsiu-mei (???), a care management specialist at the Nursing Home affiliated with the Douliou Branch of National Cheng Kung University Hospital, all caregivers at nursing homes face potential legal liabilities when something goes wrong.

If elderly patients fall accidentally when not bound by restraints, for example, they can die of undetected complications caused by the fall. In such cases, it's usually the nurses rather than the facility operators who are sued and subject to jail time, Kao said.

Finding enough skilled workers is also a challenge, Kao said. Patients who require restraints must be untied every two hours, and be carefully examined by nursing personnel every 15 minutes for any possible harm, such as tissue necrosis or blocked blood circulation.

"Professional expertise and skills are necessary. Otherwise, it's almost inevitable that one will face disputes or even lawsuits," Kao said, arguing that the lack of manpower and substandard training and facilities must all be resolved.

There are even conflicts between nursing personnel and facility operators on the "zero-restraint" care model, with many people in the business who do not have backgrounds as nursing specialists opposed to it, Kao said.

In addition, many stakeholders are involved in elderly care and whether restraints should be used, namely the patients, family members, and the care teams (doctors, pharmacists, nursing personnel, social workers and religion advocates).

Thus, no single person or entity decides whether restraints are necessary to keep a patient safe or not, compounding the problem of quality of care. That has led Kao to propose "overturning" existing care models.

Kao suggested starting by establishing service practices and professional skills aimed at helping seniors live out their lives with dignity and having the government take the initiative to foster talent in the long-term care sector or hire professionals to do the job.

The senior nurse has expressed hope that the government's "long-term care 2.0" policy could reinvigorate Taiwan's care services sector.

To Liao Chih-feng (???), who has been involved in long-term care services for 20 years, "the best care model is the one most favorable to seniors," he believes.

Liao heads a Yunlin-based private institute that teaches and promotes the "zero-restraint" care model, which is designed to help seniors recover or maintain their ability to live at least somewhat independently.

He, like Kao, sees one of the model's shortcomings at present as the lack of professional workers trained in this area.

But an even bigger problem, Liao says, is the willingness of assisted-living facility operators to provide a higher quality of care by helping seniors become more independent, regardless of manpower costs.

Liao suggested that the government learn from Japan, where the care model did not become popular until local governments ordered that it be carried out at nursing homes.

Like Liao, Lai Chin-ting (???), director of the Federation for the Welfare of the Elderly, advocates a "zero-restraint" model but said certain realities can make it hard to stick to this ideal.

He said he once saw a caregiver has to attend to eight seniors at the same time, which involved managing their meals, dealing with their calls from nature, and cleaning them up. The person had a tight work schedule that left no time for a meal, Lai said.

Also, most family members tend to give their consent to nursing homes to tie patients down if certain situations arise, such as attempting suicide, harming other people, taking diapers or tubes off, or moving restlessly.

The family members tend to agree because they feel bad when see their loved ones suffer from repeated insertions of a tube, Lai said.

"When the problems of manpower, care efficiency, and family members' demands have to be resolved, the elderly's liberty and dignity are no longer priorities," he concluded.

Lai said people must change the mindset that putting older family members in a facility means they "will stay there until death," because with proper rehabilitation, seniors can go back to live with their families.

The elderly welfare activist admits, however, that only by increasing nursing personnel and putting in advanced rehab equipment can the quality of life of the seniors improve.

Ultimately, the move toward restraint reduction will depend on devoting greater resources to long-term care and getting people to change the way they think.

But the goal of "zero restraints" may be elusive because restraints can still provide important functions, says Yao Chien-an (???), a family medicine physician at National Taiwan University Hospital.

"Restraints are not a necessary evil," Yao said, and if they can be avoided they should.

When there are no other alternatives, however, they can be seen as a last resort after a careful assessment, he said.

Source: Focus Taiwan News Channel