Autonomy and Health
The fine balance necessary between these two standards is never clearer than in the recent Florida death of an 86 year old female resident of an assisted living facility. She signed herself out, went to a local grocery store and then drove off of a boat ramp. She was found seven days later drowned. The media and community reaction varied. It ranged from suicide being her goal, to memory loss and directional impairment, to “the right to die” her way. Had she been residing in a nursing home, she would probably not have had the autonomy to check herself out and drive away. However she would have had a regular assessment of depression—in the case of suicide; and cognitive decline in the case of memory loss and directional impairment.
Assisted living residents tend to be healthier and have more financial resource. Autonomy comes at a high price. There is no requirement for a quarterly review of the resident’s adjustment, changing conditions, or health plan. The “social model” is assisted living’s theoretical foundation. The environment is often more home-like and less restrictive. The resident is expected to do more activities on their own; there is less structured provision of leisure pursuit. Some offer advanced care options that provide more of the medical oversight that is needed as senescence and chronic disease takes place. Others do not.
On the opposite side is nursing home care, the “medical model.” This has traditionally been institutional in décor, in schedule and in care. Federal regulations mandate attention to medical and psychosocial health. This includes inter-disciplinary care plans quarterly or as needed for significant change. Autonomy is often undercut by medical oversight. Efforts to lessen the institutional nature have come far, but there is still far to go.
Wouldn’t a perfect healthcare setting offer both autonomy and good health? Shouldn’t Medicaid and Medicare be willing to cover the provision of this ideal setting? There are a few spots where this is true: senior care centers embracing the Eden Alternative; long-term care residences offering Dementia Special Care Units; the Dementia Care Foundation in Minnesota. The provision of both is rare. Yet they provide the optimal marriage of senior care: Autonomy and Health. Mary Zelter may still be here had she had medical oversight along with social autonomy. Her death is the opportunity to take a more critical look at valuable senior care.