Long-Term Care

During the 1980s and 1990s, long-term care facilities came under legal scrutiny, spurred primarily by exposés of neglectful and abusive care of elderly, vulnerable, and often demented institutionalized patients. The nature and degree of the abuse offended legal, moral, and civic sensibilities, resulting in a framework of federal and state regulations governing many aspects of institutional practice, such as staffing patterns and record-keeping procedures.

Long-term care facilities are now being challenged about policies that automatically hospitalize residents at the end of life or that impose life-sustaining treatment with no provision for evaluating, preventing, or terminating such treatment. Many facilities are afraid to adopt policies that would allow residents to die in the nursing home because they fear accusations of neglect and abuse, despite assurances by state regulators that they look for evidence of thoughtful decision making responsive to the needs of individual residents. The legal and ethical climate suggests that resident-staff-family discussions about future and, especially, end-of-life care should begin soon after admission to a nursing home and not at a time of crisis. In response to the Patient Self-Determination Act of 1990 and because of concerns about legally supportable care decisions, many facilities are discussing future care, including CPR, with their newly admitted patients. Decisions should be reevaluated periodically based on changes in the resident's physical condition and the goals of care for the resident.

Federal and state laws and regulations also govern long-term care financing. Most elderly patients and their families do not understand the complex rules that require poverty-level status before Medicaid will assume the cost of long-term care. In most states, legal advocates can protect a spouse living in the community from impoverishment by appealing to state regulations that permit the segregation of shared funds for the benefit of the community-dwelling spouse. If such an arrangement is not possible, an attorney can file a suit for support in family court or in another appropriate state forum. Every state has a long-term care ombudsman whose office is funded by Medicare. These offices can provide information about some of the rights and protections available to residents of long-term care facilities.