Nutrition Care Plan refusal is a very common issue facing Long Term Care Dietitians. Dietitians need to ensure they know exactly how to respond to this. Read this article to learn about the patient’s right to refuse and how the Long Term Care Dietitian needs to respond and document.

Patients and Nutrition Care Plan Refusal

Have you ever made a perfect nutrition care plan and a resident refuses to follow it? I have!

I went to school, have completed hours upon hours of training on safe feeding and swallowing, decreasing risk associated with diet textures, found the importance of preventing weight loss, I thought I knew it all. But I didn’t.

Some of my early days I had a steep learning curve learning how to deal with a resident refusing the nutrition care plan treatment.

In the resident bill of rights, they all have the right to refuse treatment.

Common Nutrition Care Plan Changes

This is a list of the common nutrition care plans that require a long term care Dietitian to be flexible in changing:

1) Refusing a modified diet texture that will reduce their risk of aspiration/choking.
2) Refusing to have their weights checked monthly (or weekly depending where you are).
3) Refusing to eat some or most of their meals, risking serious nutrition deficiencies, weight loss, increased frailty.
4) Refusing to get out of bed for meals, increasing their risk of choking due to improper positioning.
5) Refusing oral nutrition supplements prescribed, increasing risk of weight loss, frailty, delayed wound healing, etc.
6) Refusing thickened fluids due to increased risk of aspiration pneumonia/silent aspiration.

These are just a few examples of residents refusing care that I have offered a plan for.

How Does a Dietitian Document Care Plan Refusal?

All Dietitians need to know how to document in a patients chart properly in order to not get into some serious trouble when they’re being audited.

There are obvious concerns that arise from the list above. You know as a health care professional the health risks that are associated with all of those. So what can you do as a Dietitian to minimize these risks?

Step 1: The First Consult of a Patients Refusal

When the Dietitian receives the first consult that a patient is refusing some area of the nutrition care plan. Such as diet texture, it is the responsibility of the Dietitian to ensure this has been written in the chart.

This begins the chain of communication. If the Nurse says they have not charted on it yet, just kindly ask that they do so that you can write a response. This needs to be done, if you get audited and the chain of communication doesn’t make sense, you will be questioned. Especially with something as serious as refusing treatment with increased health risks.

Step 2: Communicating with the Patient and Family

The Dietitian should then set up time to discuss with the patient and/or their family about the risks associated. There are always going to be some type of risk associated with refusing a nutrition care plan. I’ve written some of those risks above.

When discussing with the patient always find out what the true issue is. There is possibly a compromise, or maybe there is simply a middle ground that they’re looking for in their care plan. Maybe they aren’t really wanting to change their care plan, they just want more flexibility in meal choices.

The Dietitian will educate the patient on the risks associated and if they choose to accept, this needs to be written into a very specific chart note. I like to write out exactly what risks I discussed and use quotations when I write their responses.

Having a document where they sign a waiver indicating their understanding doesn’t do much. For this reason, I just worry about documenting their acceptance.

The purpose of you educating them on the risks is not to shame them into accepting the nutrition care plan. The purpose is that they truly understand that there are serious risks associated with it.

According to the Medicaid standards about a patient’s right to refuse care, they say the following (click here to read more):

Step 3: Changing the Nutrition Care Plan

Now you begin the process of making the change.

If the Speech Language Pathologist (SLP) has been involved in the patient’s care, you should give them a call about the change. They should be involved prior, but typically they aren’t available to come to the facility right away.

You should also connect with the Nurse and Health Care Aide’s on the unit about the changes so they don’t send back the diet texture thinking it was a mistake. You then go about whatever the process is within your facility to inform the Dietary department about the texture changes.

Step 4: Documenting Nutrition Care Plan Refusal

Here is a Sample Chart Note on how to Document:

A – RD was consulted by Nursing that the resident is refusing their modified diet texture, minced texture. RD interviewed resident who stated, “I will not eat the mush texture that I got for lunch today.” RD explained the risks of going on a Regular/Standard texture diet: Choking, Aspiration, Aspiration Pneumonia, Hospitalization, and they were accepting of all risks, resident also approved RD to phone POA to be in agreement. RD phoned POA (Debbie Reynolds) and explained the discussion with resident as well as the health risks associated with changing diet texture, POA stated that it is up to the resident, and she is in agreement with whatever the resident chooses to do.

D – Swallowing difficulty related to post stroke complications as evidenced by coughing on regular/standard diet texture.

I – Resident will receive a regular/standard texture diet as requested, aware and understanding of health risks associated with change, POA in agreement. Nursing, Dietary, SLP, all informed of change to take place.

M/E – Nursing has been requested to monitor resident at all meals, ensure resident is in main dining room for observation/safety purposes. RD will visit resident in 1-2 weeks to assess how regular/standard diet texture is for the resident. RD available for consult at anytime.

Note that in the chart note:
1) I have written exact quotes the resident stated.
2) I have written that I have explained the health risks to both the resident and POA, both were accepting.
3) I have written the different disciplines that are aware of the changes being made (Nursing, Dietary, SLP). This will help that you are not the only one aware of what’s going on.
4) Put precautionary measures in place –> Can only eat in a dining room that is constantly monitored, resident cannot eat in bed, made yourself available for consult at anytime.

These are all ways that you ensure you have covered yourself in terms of making sure everyone is aware of what is going on, the resident and POA are aware that there are SERIOUS health risks with the decision, and that you have properly documented everything. Always make sure you speak with others about a change as significant as this.

Don’t forget that you need to change the residents care plan and MDS! I like to get everything done in one shift if I can for something like this so that I don’t forget anything.

I understand that as an RD it is hard to see a resident go against your expertise, but remember, this is their life, and if you were in their position, you would appreciate a compassionate RD who respects their choices.

There is what we learn in textbooks, but we need to leave room for quality of life to balance in the equation.

Everyone in LTC has the right to refuse, the Long Term Care Dietitain’s job is to educate them on the risks associated. Just make sure that one of the most important thing is to document, document, document!

Make sure the chain of communication has continuity so if you do get audited and they check that chart.