Judge Strikes California Law that Allowed Nursing Homes to Make Medical Decisions for Unbefriended Residents

I just updated my prior articles on decision making for adult orphans, unbefriended, unrepresented patients without surrogates (forthcoming 26(2) J Clinical Ethics).  And then this.



A California law allowing nursing homes to make medical decisions on behalf of certain mentally incompetent residents is unconstitutional, a state court ruled this week.



The law, which has been in effect more than 20 years, gave nursing homes authority to decide residents’ medical treatment if a doctor determined they were unable to do so and they had no one to represent them.



Alameda County Superior Court Judge Evelio M. Grillo wrote in the June 24 decision that the law violates patients’ due process rights because it doesn’t require nursing homes to notify patients they have been deemed incapacitated or to give them the chance to object.



Grillo acknowledged the decision is likely to “create problems” in how nursing home operate but wrote that patients’ rights are more compelling.



“The stakes are simply too high to hold otherwise,” the judge wrote. Any error could deprive patients of their rights to make medical decisions that “may result in significant consequences, including death.”



The medical decisions on incapacitated residents without representatives are made by a team that includes a physician and a nurse.



The fact that nursing homes are making end-of-life decisions without patient input is a big concern, according to the ruling. The decision cited one nursing home resident who was found to be mentally incapacitated and who had no representative. The facility staff made a decision to take him off life-sustaining treatment and he passed away in 2013.



The ruling came after the California Advocates for Nursing Home Reform, an advocacy group, filed a lawsuit in 2013 against the state Department of Public Health. The suit alleged that nursing homes used the law to administer anti-psychotic drugs, place residents in physical restraints and deny patients life-sustaining treatment.



Tony Chicotel, a staff attorney for the group, said the ruling will dramatically impact the lives of the most vulnerable nursing home residents.



“What [nursing homes] used to do was routinely make decisions big and small for their residents without really any regard to due process,” Chicotel said. “Now the residents are finally going to have their rights acknowledged and honored.”



Even patients who are compromised should still have a say in their medical care, he added.



“They have been ignored,” he said. “Unrepresented residents and the way they are treated in nursing homes has never been a priority of the Department of Public Health.”



The department is reviewing the decision, a spokesman said. Department officials declined to comment further or say whether they planned to appeal.



The law was enacted in 1992 because nursing facilities needed a way to give medical treatment to their incapacitated residents without having to wait up to six months for state approval, according to the ruling.



But the decision could make it challenging for nursing homes to provide routine medical care or to offer hospice care to residents who lack the mental capacity to make their own decisions and have no designated representatives, said Mark Reagan, an attorney representing the trade group, California Association of Health Facilities, which is not part of the lawsuit.



“If the person objects, then what?” Reagan said. “That can put patients and facilities in a difficult place.”



And seeking court approval to provide anti-psychotic medication to residents who truly need it would be costly and time-consuming for nursing facilities, he said. “How do you keep that person safe and how do you keep the other residents of the skilled nursing facility safe?” he said.



Reagan believes the ruling could have an unanticipated outcome: Patients without decision-makers could have a hard time finding a nursing facility willing to take them.



“If this decision makes it more difficult to supply necessary care at the bedside, this population is going to be less served,” he said.



The judge, however, wrote that informing patients and allowing them to object is not likely to result in any significant burdens on nursing homes.



Golden Gate University Law School Professor Mort Cohen, who filed the case, said the next step is for the judge to issue an order directing the state Department of Public Health, which oversees nursing homes statewide. The state could ask the court for a stay or could appeal the decision, but Cohen said he expects the decision to stick.



[From Kaiser Health News (KHN), a nonprofit national health policy news service.]