Care Planning in Residential Care

When a person is being admitted to the residential care facility for more than 30 days, the operator is required to develop an individualized care plan for the person. Sections 81 and 82 of the Residential Care Regulation sets out the components of a care plan. The operator has a responsibility to ensure the care plan is properly implemented, reviewed if there is a substantial change in circumstances, and if there is no change, the plan must be reviewed at least once a year.

By law, the resident’s care plan must be developed (and later reviewed or modified) to the extent reasonably practical, with the participation of the resident, or if the person in care is not capable of participating, with the resident’s “representative”. The term “representative” as it is used in the Residential Care Regulation means a person with authority under the Health Care (Consent) and Care Facility (Admission) Act (including a TSDM) or the Patients Property Act, or under an agreement under the Representation Agreement Act to make health or personal care decisions on behalf of the adult. This is a relatively circumscribed group.

In some instances, particularly where the resident has not formally appointed his or her own substitute decisionmaker, the health care provider relies on the statutory list of substitute decisionmakers. Some health care providers in residential care skirt the process and turn to the person they feel will be most supportive of the decisions they want to make, as opposed to one who knows what the resident wants best. The care plan is also required to be developed in a manner that takes into account the unique abilities, physical, social and emotional needs, and cultural and spiritual preferences of the person in care. The care plan is not intended to be a one way process of care providers deciding what is needed or they believe is in the resident’s best interest. Residents have the right to have it developed “on the basis of his or her unique abilities, physical, social and emotional needs, and cultural and spiritual preferences.” That typically involves information from the residents and those who know the resident well.

Consent and Care Plans

Several important consent issues come up in the context of the care plans. First, care planning frequently becomes conversations among care providers only; the resident is treated as incapable and therefore excluded. A 2011 review also found families in British Columbia experience challenges in interacting with health care professionals and residential care facility staff. These included:

• family were not being effectively included in the care plan development
• their legal authority as health care decision makers (including as temporary substitute decision-makers) was not recognized and respected
• their consent was not sought when treatment options are considered and provided.

Specifically family might not be informed about the care conference or were given short notice; people might not be advised of their role and how they might participate more effectively; residents and others are not given real opportunities to help inform the care process; and key persons such as physicians were not part of the conference.

Informed consent is typically based on having good information. The BC Ombudsperson’s Best of Care report has identified the following concerns from residents and their families:

• lack of adequate understanding of the level of care that seniors are entitled to receive in residential care facilities;
• reluctance to raise concerns about the level of care that facilities provide, in part because they were not confident about what residents were entitled to receive or what their rights were;
• the risk of raising concerns because residents were dependent on others for their care;
• lack of good understanding of the legal obligations of facility operators;
• difficulty determining who was responsible for the delivery of specific services and with whom concerns about these services could be raised. This was especially true when service delivery was contracted out to third parties.

Rights Associated with Care Plan Consent

The provisions of the Health Care (Consent) and Care Facility (Admission) Act also apply to residents of long-term care facilities. A Care Plan involves a combination of health care and personal care decisions, as well as in some instances, financial decisions. The resident has the right to participate in the assessment of his or her physical and mental capabilities, needs, and preferences, as well as in developing and revising a plan of care.

In order to be able to participate meaningfully, residents have the right to have someone explain to them, in language and terms that the residents understand, what has been assessed and how, as well as the proposed plan of care. After being informed (in plain language) of the consequences of any proposed treatment, and of not receiving the treatment, the resident has the right to give or refuse to give informed consent.

Residents have the right to request and receive a "second opinion" from an independent health care professional, regarding any aspect of their care. The resident has the right to be involved in, and receive independent advice regarding any aspect of the resident's care. This includes any decision regarding the resident's discharge or transfer from the facility, and would also include any decision regarding transfer of the resident within a facility, (i.e., moving to another room or wing).

Advance Care Planning - Advance Care Plan and Advance Care Directives

Advance care planning is the communication process between a capable adult, family or other key people in their lives, and health care providers to ensure that the adult’s beliefs, values and wishes for future health care are known in the event that the adult is incapable of making health care decisions when the health care is required. Although advance care planning is supposed to be an ongoing process of communication, health care providers are often given the impression that it is a linear process and that once the documentation is done, the process is complete.

Advance care planning was originally intended as a process by which people could exert their autonomy over what happened to them, in the event they became incapable and were no longer able to directly express those wishes. Unfortunately it has sometimes become a process done to and imposed on the older adult, as opposed to done with the older adult.

An advance care plan is a written summary of a capable adult’s beliefs, values and wishes for future health care, in the event the adult is incapable when the health care is required. The plan may simply be a statement of wishes, or it may include an advance directive or a representation agreement in which the adult names another person to make health care decisions on behalf of the adult.

An advance directive is a legal document that provides consent or a refusal for certain types of health care in advance of the need for health care arising. It is a capable adult's written instructions expressed directly to their health care provider, or to their representative if they have named one in a representation agreement.

Advance directives are legally binding documents and only apply to health care. To be a valid advance directive, it must comply with the requirements for the instructions, plus how it is signed and witnessed. Under the Health Care (Consent) and Care Facility (Admission) Act, an advance directive:

• must not be mandatory - an adult must not be required to have an advance directive as a condition of receiving any good or service.
• may not include anything that is prohibited by law or an instruction to omit to do anything that is required by law.
• cannot include instructions about any types of health care restricted for a temporary substitute decision-maker.

This information applies to British Columbia, Canada. Last reviewed for legal accuracy by BC Centre for Elder Advocacy and Support, June 2014.