PELI Webinar: Honoring Preferences when the Choice Involves Risk

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PELI Webinar: Honoring Preferences when the Choice Involves Risk

Hello and welcome to the Preference Based Living webinar on Honoring Preferences when the Choice Involves Risk My name is Katy Abbott and I am an assistant professor at Miami University and a Scripps Gerontology Fellow and I am honored to have two esteemed guest presenters today, Jennifer Brush and Dr. Maggie Calkins, join me. And I’ll start with some introductions First, Dr. Caulkins is nationally recognized as a creative, dynamic leader, trainer, and researcher in the field of environments for elders. She is president of IDEAS, Innovative Designs in Environments for an Aging Society, a consulting firm dedicated to exploring the therapeutic potential of the environment, social and organizational, as well as physical, particularly as it relates to frail and impaired older adults She is a highly sought after speaker for conferences in the United States and abroad. She has published extensively and received over 5 million dollars in grant funding from the National Institutes of Health and Foundations to develop training materials and explore the impact of the environment on people with dementia And our next presenter is Jennifer Brush who has a Certificate of Clinical Competence and Speech-Language Pathology. She is an award-winning dementia educator, author, and consultant She’s passionate about enriching the lives of people with dementia Jennifer is on a mission to put the focus of care on the person’s preferences, interests, and abilities With her 25 years of industry experience, including leading countless live national and international trainings, facilitating groundbreaking research, and managing innovative person-centered projects for the Ohio Council for Cognitive Health, Jennifer flawlessly bridges the gap between care communities and the individuals they serve Jennifer serves on the Association Montessori International Advisory Board for Montessori for Aging and Dementia and as the program director for the National Center for Montessori and Aging at Cross Way Community. She is the only Association Montessori International certified educator for Montessori for Aging and Dementia in the United States, and we are delighted to have them both as presenters All right, so about this series, this webinar is part of a quarterly series we host to disseminate our findings from our research and collaborations with our stakeholders We have lots of other webinars that we have recorded and can be found on our website We have topics about integrating preferences into care, we have topics about helping staff engage, we have topics about when you can’t ask the resident, how can you involve proxies? And so all of those webinars are on our website and you can access them at any time All right and next slide So, I will take it from here, this is Maggie Jen and I are doing the presentation together. I’m going to do the first half and Jennifer will do the second half So briefly the objectives for this webinar are to help you recognize nursing home and assisted living code language that supports the residents’ rights to make decisions, even when it carries risk, and how you balance that when you are providing care We’re going to list and describe the four steps of care planning for resident choice, a process that we have developed with input from a number of experts, and we’re going to demonstrate your understanding of the process by completing a case study or two And that’s where we really need your input in the chat box area And we’ll be doing some of that throughout the whole webinar, so I hope that you will all participate and share your ideas with us as we move forward I think it’s always helpful to begin with sort of a framework and there are lots of different kinds of definitions for person-centered care The way that we have framed it is that there are these four sort of core components or values. One is choice, which has to do with ability to personalize spaces, to choose between spaces that are meaningfully different, choice in food and dining, what to eat, when to eat, where to eat,

bathing options, whether you take a bath or a shower, how frequently you get to do that, is that on a regular schedule or can you decide on any given day whether you want to take a shower today? The second is meaningful engagement, so it’s having space for people to gather and do things in, but also space for private conversation Some care communities tend to focus primarily on larger group activity space and having some smaller spaces for contemplation or meditation can be very important. And then you want to have the spaces that really support engagement in activities The third is comfort and dignity, which is, you know, refrigerator rights, being able to have free access to food and beverages And that carries some risk, we’ll be talking about that later on Easy, accessible drop-off point for people receiving care, or for family members who are coming to visit And then the final one is community or outdoor spaces Having direct access to outdoor courtyards and having that access be largely unrestricted is important. It goes back to that issue of choice and control Support for the physical challenges that older adults are experiencing, so how we help them manage any physical frailties or use the environment to compensate for that frailty so that they can continue to be as independent as possible But for us it also means engagement with the wider community and keeping people interacting with not just family who might come and visit them in a secured memory living area, but having them have the opportunity to leave that living area if they want and go to other places of the care community or out into the larger community to restaurants or to shopping or to museums and things like that So that’s the basic framework that we use And what we’re talking about today is when a person wants to do something that the care community, the care providers, maybe family, view as risky and are thinking about potentially not accommodating that preference, how do you manage that? This could be in terms of diet choices Whether it is a diabetic who wants to eat a dessert or something else that has more sugar in it, whether there are modified textures Jen can talk about thickened liquids and the fact that they are not been shown to be effective in managing aspiration risk But often we see communities restricting what people can choose to eat Mobility aid use. The person who the physical therapist says should use a walker and they don’t want to because it makes them feel old and frail. They want to be able to get up and walk on their own, Someone who refuses medication We see that, again, and there are lots of different ways that communities respond when somebody is saying no. But before I go on, I really want to have you think about the wide variety of kinds of choices that people can make that may be perceived as carrying risk And it doesn’t have to be an individual with Dementia, it could be any individual living in the care community Absolutely, this is not limited to people with dementia Well, yeah, we’re seeing a couple of responses about smoking Smoking is a good choice, I mean a good issue People have been smoking all of their lives If they want to continue, should they be allowed to and how does that play out with care community rules if they’re trying to have a smoke-free environment to be healthy for other individuals? All right, well some more come up, we’ll see if we can address that but I’m going to move forward So, when a resident, when what a resident wants to do may lead to a decline or potentially a negative outcome,

do they have the right to make that decision? Do they have the right to continue to choose, to continue to smoke for instance? They were doing it when they were at home And the answer at one level is yes Just because you relocate from a home to a shared residential setting doesn’t mean that you lose those rights, but there are also federal regulations that put restrictions on care communities that are designed to support the safety of individuals So the federal regulations give nursing home residents the right to participate in care planning, the right to refuse treatment, the right to make choices about things that are important These are all in the new regs that have been implemented in the last two years and are again coming up for the third phase later this year But then you see down here be free from accidents and to maintain or improve functioning and sometimes what a person wants to do may put them at greater risk for having an accident, for instance, not using a walker when they want to get up and go use the restroom And so the care communities are in a bind In the language of the regulations, quality of life and quality of care are supposed to be equally important, but the reality is that quality of life in the past has not been given the same weight and we see that in the lack of assessment on the resident RAI forms that really focus on quality of life. Most of those items focus on quality of care Survey teams when they come in, they have to make choices when they interview a resident and they learn that the person wants to engage in activity that may carry some risk. And so they’re struggling, as the care community is struggling, with how do we honor the residents preferences but not put them in a position where they are likely to suffer a negative consequence? And so this is a moving target, it’s changing with the new regulations and there aren’t any hard and fast, firm rules So for an example, we have a resident who who wants to refuse taking a medication The nurse is worried about the consequences and, you know, what does she do? She says “Come on Walter, just take it for me this one time, just for me, you like me, it’s good for you.” Or they might try to frighten him, you know, “you’ll get that terrible swelling in your legs and it will be hard for you to breathe if you don’t take this pill.” They may hide it or crush it or just add it to food so that the person is getting the pill even though they have said they didn’t want it. They may even threaten, and I have heard this, you know, “do you want to die? If you don’t take this pill, you know, you might die,” which may be true, but isn’t necessarily the right response when somebody is refusing medication What’s not done, particularly sort of in the moment is to find out why the person, in this case, doesn’t want to take a medication. Is it that there are side effects that are worse than what they think the benefit of the medication is? Do they feel like there’s no reasonable benefit? You know, “I’m 95, I’m, you know, in a nursing home, I don’t really want to take this medication that’s going to make me live longer.” They don’t like the taste, the size, the frequency of the dose. And so this step is critical to Understanding and then working at developing effective interventions So the emphasis, like in quality of care has most often been on physical outcomes because those are things that are more easily measurable: a weight loss, a pressure ulcer, a decline in walking or a fall Very little consideration is given to the negative effects

psychologically of having a person’s preferences ignored. So for the person the value of smoking may be so great that for them, it’s more important than the harm it is doing to their lungs, or the value of going outside. And so as you start having these conversations, and Jen’s going to talk about the process in more specifics, you want to make sure that you’re looking at both, what’s the value to the resident of doing what they want to do as well as what you are perceiving is the potential risks, negative risks, negative outcome risks So the CMS new rules for participation are clearly moving in a way that emphasizes resident choice and decision making authority, and so we’re here to talk about a care planning process that is consistent with these regulations The rules for assisted living vary from state to state, but in general the values and the process is the same So what you’re trying to do is to balance their preference with how much risk is there? Umm, and often, care communities want to err on the side of safety because they’re afraid that surveyors will come in and think that they have been putting people at risk or letting people put themselves at risk and that they will get a ding on their survey. And so, as I said earlier, this is consistent with the new regulations and if you can document that you are really working at understanding and honoring the residents’ preferences and that you did this on an ongoing basis, you are following the regulations So the sort of overall process, I’m going to just describe briefly and then Jen’s going to get into details, is weighing with the person the potential outcomes, both the positive outcomes that the person sees from having their preference honored and the negative, potential negative outcomes or risks that are seen by the care community, of both respecting and aiding the person to make their choices. You review the outcomes, again positive and negative, of what’s preventing the person from acting on these choices? This is part of the education process And then you need to document it. Am I doing your section? Nope, this is about where I start. Okay, then here I am, I’m turning it over to Jennifer So this process usually starts when a person asks to or refuses to do something that the staff think is in their best interest. And it’s a four step process that begins with identifying and clarifying the person’s choice and their preferences, discussing the choice, developing a plan to honor the choice, and then monitoring and making revisions to the plan. So I’ll take you through each step individually So, when a person expresses a choice, there is an assessment of capacities that should be done And I want to make a note here that capacity is not an all-or-nothing proposition Just because someone has a diagnosis of Dementia or a major, any other kind of neurocognitive impairment, it’s not sufficient itself to justify restriction of a person’s rights So, the person still can express their preference, and if you think about people with, even with severe Dementia that you know or advanced Dementia, they might not be able to communicate verbally their wishes but their behaviors really tell us what they prefer So for example, a person who consistently resists entering the shower is communicating that they are uncomfortable with this and perhaps there’s a different way that they would like to be helped kept clean. So in these situations even though someone has Dementia, we do still pay very close attention to their behaviors,

we listen to their requests, we involve their responsible party in their decision-making, but we acknowledge that people with Dementia do have the ability to make decisions about their life So we then look at if this is a decision that Involves risk or not risk. This situation, this process that we’re talking about is a shared decision-making process when the choice involves risk So if the choice that they’re making doesn’t involve risk, you should be honoring that choice and care planning the choice and monitoring it and reassessing it. So we’re really talking about things that involve risk to the individual So the first step is to interview and talk to the person, observe the person, you know, what do you know about the person? Their past? Their preferences? And then is this request something that’s just a one-time request or refusal, or is it something that’s ongoing? So maybe someone just doesn’t want to take that, their pill that one day or maybe they don’t want to take their pill ever again. Okay you know, maybe they don’t ever want a feeding tube or they want to shower without assistance for a particular day So finding that reason that the person desires the choice, and then what about that choice is different from the care community’s recommendations Don’t just assume that you understand the person. Repeat back to the person your understanding of what he or she desires Okay, so that’s an important part of this process, that you use good listening skills, that you let the person communicate and that you then repeat back what your understanding is And this is a full team process. We want the multidisciplinary team there We want anyone there that the individual would like to represent them Even if the individual is their own decision-maker, they might choose to have family or friends there with them Direct caregivers, the people that spend the most time with the person, should be there as well. And this is now, during this discourse you’re determining if the individual’s choice presents a perceived risk or safety challenge to that individual, to other residents, or to the community So clearly people have less rights when they put other people at risk, okay, than if the risk only falls to that individual If the choice that they want to make Represents a change in the care community policy or the resulting options stretch the community’s comfort level, then that multidisciplinary team and leadership from the community, so the medical director, the administrator, should really be involved in that process. So, there’s a lot of discussion, and then the important, very, very important part of this is documentation of that discussion. If this isn’t documented, it never happened When a surveyor comes in, they need to see documentation of this process, of the entire process with all the steps, not just a few notes in someone’s medical chart that you’ve educated the person about something So what we recommend is that you document very specifically in as much description as possible the person’s preference and why it’s important to the person, then your or the team’s safety risk or concern, who is representing the person, if anyone, it might just be themselves, and then who on the care team was involved in these discussions. And this may not just be one meeting, this may be a series of meetings and discussions. The individual may bring up a concern to one staff member and then you may share it and hold a series of meetings with other staff members So here’s an example of an individual who wants to spend time outside in a fenced-in patio unsupervised He wants to go out whenever he desires and he wants to be able to go on short walks and sit in the sun and he does not want anyone

watching him, it makes him feel like a small child He wants to sit outside and read the paper and do what he’d like, just like he did at home He walks with a walker though, he’s had a stroke in the past, and he had a fall in the dining-room so the staff are concerned He manages his own affairs So the second step in the process once you’ve clarified the choice is really to explore different options. This is the time to explore different options that would be mutually acceptable. And a big part of this is discussing with and educating the person about the potential outcomes of respecting and aiding the person in his or her choice, but also the potential outcomes that are associated with preventing the person from acting on his choice. You know if you think about it all day every day, we make choices in our life that are very simple and some that involve risk So we make choices about what we want to wear and eat and getting in a car and we make decisions that involve risk for ourselves, for our children on a daily basis. When you start taking away the ability to choose from someone, you really negatively impact their sense of well-being. And so we should be aware of that when individuals are living in a shared residential setting, the number of choices that they’re able to make about their life can significantly decrease So this is the time to talk about the positives and potential negative consequences of making the choice The staff need to keep in mind that the individual still has the legal and ethical right to make choices and to refuse treatment. And then after hearing the positive and negative consequences, you know, the person may change their mind. They may decide that they don’t want to make that choice or that they might make a different choice or they still may want to continue with their original choice. So this is the time that you are going to offer and brainstorm as many ways as you can to accommodate that choice, but not only accommodate that choice but mitigate risk You know, it’s our responsibility to honor their choice but also to maintain their quality of health and their quality of life, so to offer different options to that individual. And then again, this part of the process is documented So what are the potential benefits for honoring the choice? The potential risks for honoring the choice? What different alternatives were discussed? What education about the consequences was provided? And then who was involved in those discussions? I’m going to step in and make one quick point. On this form, we very specifically put benefits first because it is so easy to start by looking at the risks and not ever think about what are the positive consequences of, to the individual, of accommodating that risk? And so by putting it in that number one position, we really wanted to get the care communities to step into the sort of the eyes of the person that they are caring for and see what it is that they want and make sure that that’s a part of this process. So for example, someone who is at high risk for falls but it’s very important for them to walk on a daily basis, that’s been part of their routine for their entire life. And so for that person, it is better for them to risk falling than not to walk around. And then so then we need to look at what options do we have to keep them safer at doing the thing that they enjoy doing? So for the resident who wanted to be outside, by honoring that choice it enhances his dignity, okay, his self-esteem, his autonomy, and he gets benefits from being outside in the sunshine. It provides him an opportunity for exercise

The staff see potential risks as fall, sunburn from sitting outside, not knowing where he is in case of an emergency, that if he fell he might be outside alone and perhaps people might not know that he’s there It was proposed to him that he only go outside when there’s other activity programs occurring so that someone would be able to keep his eye, keep their eye on him and that was rejected He said he wanted to be in charge of when he used the patio The nurse talked to him about weakness from the stroke, both to his hand and his leg, how some of the sidewalks may be difficult for him, how some of his medications make him more susceptible to sunburn. So they had this discussion, documented the discussion, and then the third step is really creating that plan. Writing that plan down to honor that choice. How are they going to, specifically what was the agreement for accommodating the preference to maximize that individual’s well-being? What are the steps that the staff will take to support that choice? And putting that in the care plan, involving again the direct care staff that have as much, the most contact with the person, and involving the person’s representative if there is one. And realizing that that means sometimes involving the person’s representative means that that’s a phone call, you know a conference call, a small meeting rather than a larger meeting, you know understanding that there’s different ways of having these meetings to plan the choice and that we need to accommodate people’s preferences with that as well So now this is care plans and the steps take place. So what’s the option that of all the options that were considered, is there something that’s acceptable? If there isn’t something acceptable and the choice was denied, why it was the choice denied? And what other actions or consequences will be in place? And again who was involved in the decision? So, in our case study case, the individual rejected the option of going outside when activities were going on He retained his original desire to go outside whenever he wants, and the care team honored that choice They asked for a physical therapy assessment to assess walking and safety and make recommendations He recommended some gait training outside and switching to a wheeled walker, with a seat and a break, and some new shoes that were sturdier and gave more support for his ankles, and the individual agreed to those recommendations He also agreed to wear a hat and sunscreen on sunny days And then the individuals who are at the meeting, that’s documented on the form as well Now, as a person changes over time or as different ideas or options are considered and tried, as their needs or their preferences or choices change, care plans need to be flexible Staff should be flexible about this. People have a right to change their mind. And when we talk about monitoring, that should never be limited exclusively to auditing forms and records. This should be observing the person, talking to the person, communicating with them, communicating with their responsible party, at frequencies that are appropriate for that particular choice So this needs to be, you know, a living, dynamic document that is updated and changes are made to reflect the person’s needs. Just like we change, the care plan needs to change as well. And then we recommend that the care community’s quality assurance and performance improvement team look at trends related to resident choice and safety, particularly when the residents are routinely denied requests or when the team identifies patterns of a community care practice that might be improved by performance improvement action plans So, and then these topics should be considered, you might want to consider talking about these topics also at

resident or family counsel meeting. So things that are denied on a routine basis, inability to accomodate individuals’ preferences, listening to family or resident council feedback, if you have a high frequency of high level risk requests or activities When we developed this process, we developed it with input from over 50 healthcare professionals and legal experts. We had elder law attorneys on the team, we had state surveyors on the team, nurses, researchers. It was a very diverse group of individuals. And after we spent quite a long time developing this process, it was then reviewed by an additional five healthcare professionals and ten state surveyors who were not part of the task force. And then we modified this process again based on their comments. And then after that we had 11 different long-term care communities use the process in collaboration with at least two residents who wanted to make choices that they felt, the staff felt involved risk and they completed an online survey and we also, they also participated in some focus groups So these are the the states where individuals participated and what we found that the process was used for 27 different preferences, most often to address food-related issues, things like diet consistency or fluid restriction, individuals not wanting to be on a diabetic or specialized diet Unattended access to the outside was the next most frequent use. And then other common preferences, including smoking, which came up today, bad alarm use, refusal of treatment or other medications We were pleased that all the care communities said that they were either very likely or definitely going to continue to use the tool. We had a community incorporate it into its electronic health record Some of the communities said that they felt the form, the process was just too long and it was too redundant. And we really listened to this feedback and we cut the process down from six steps to four steps. And so the process that’s available to you is the revised four step process and as well as forms that are filled in, a tip sheet, and then forms that are blank that you can use, you can make part of your medical record, you can photocopy However you’d like to use those in your community, they are available to you, you’re welcome to use them So what we’d like to do now is take you through some examples of common scenarios that we’ve encountered and get, open this up now to some discussion with all of you about how you would walk through this process with these different scenarios Or if you have a situation in your care community that you think fits within what we’re talking about and you want to bring that up and write a, you know, two sentence case study, you can do that as well So we’ll start with this first one on Mrs. Cardiff who is tired of having her diabetes checks done They’re currently being done on a daily basis and she is tired of having her fingers hurt from the finger sticks So, how might you approach this process? So just to remind you, we want to gather information about her preference, we want to educate her about potential negative and positive outcomes, have a discussion about that We want to offer different options that would honor her choice while mitigating the risk to her

The first comment is to reduce the number of times the checks are done during the day So that’s a comment that’s jumping directly to a solution and it’s a possible solution, it’s one of the options that might be considered But as Jen was saying, we want to make sure that you are thinking about the other steps in the process. So before just reducing the number of times, it might be worth asking her questions about, is it always done in the same finger? Maybe it needs to be looked at as other ways of getting the information So you want to be asking her what her preference is and what it is that is driving that before you start brainstorming really on all of the different solutions Review recent blood sugar history to determine the level of risk. That’s a great comment, that’s part of that information gathering Maybe she’s on a medication that is really controlling her blood sugar quite well, and she doesn’t need to be up to have a blood stick every day or multiple times a day And so that’s a way of bringing more information to the table If it shows that in fact, her current medications are not controlling her blood sugar levels, then maybe having another evaluation with doctor and trying another medication More closely monitoring her diet So again, looking at what is her current diet sort of patterns? And if she’s following or if she’s not following a recommended diabetes-based diet Maybe one of the ways of getting to a place where she doesn’t need to have her finger sticks done as often is if she’s better in her diet management. And so these are all great examples of the kinds of issues that you want to be exploring in that phase 2 and step 2, and looking at the different kinds of options that might impact this issue Let’s try another one Jen So Mrs. Jones moved in a few weeks ago and she says she wishes to take her bath unsupervised, she can’t relax when she’s being watched But staff were concerned, are concerned that she’ll slip and fall so they don’t want her, they do not want to allow her to bathe unsupervised So, what would you start off with in this process? What’s the first thing that you should be asking her and talking to her about? So we’ve got someone about, someone saying, Paul is saying, talk with the resident about other ways to provide privacy while having an aide present, like a privacy curtain Cheryl has suggested, what risk is she comfortable with? Tonya has suggested, is it a particular staff member? Mm-hmm. Good. Sorry, we weren’t seeing those. We’ve been waiting now we’re seeing them. But yes, what was her bath routine, that’s very important You know, we all have our bathing routine, it’s so automatic, right, and we’re so tied to those personal care routines So, you know, that’s really important. If she had help in the community prior to arriving to the care community, yeah, what was the routine and how they did it? So those are all important questions to ask

She might be comfortable with having a staff member present, but a curtain drawn, right. Or maybe she might be comfortable if part of her body was covered And it might also be important to know What kind of a tub she used to have and is that comparable to the tub that you have here or is it, you know, is it a different kind of equipment? Most tubs in the larger community, you know, you have to step over at the top and Sit from a standing position all the way essentially down on the floor Maybe she had some adaptive equipment that made it easier for her to be able to do that And so, also looking at the physical environment of the bathing process is an important step. So all of that information gathering about how she got in and out of the tub. What was the tub like? Did she have assistance? Had she ever had a fall related to bathing? You know it may be that she’s sufficiently aware that bathing is a time when she might risk falling, that she’s super cautious and has, you know, non-slip things on the bottom of the tub and always uses the grab bars and that, if at other times when you know, she’s just walking down the hallway or across the dining room and she’s not thinking about it that is when she really is at a risk for a fall So exploring those kinds of issues She might just need help getting in and out, but she can bathe by herself so then that is a time that she can relax and you know doesn’t have to feel like somebody is watching her. I mean it’s such a private time, nobody wants to be watched when they’re bathing or toileting Any other? In terms of brainstorming, um chooses to eat things like, okay, so someone just wrote if she chooses, I think this is from the last one,to eat things she shouldn’t and she’s requesting a waiver, okay So I’m going to jump, I’m going to say something about waivers here. I’m glad that word came up, it’s a terrible word When we first started this process several years ago, one of the reasons that we did this is because people, communities were giving people waivers. And we met with a whole group of lawyers Originally we, this task force group that we had we called a legal task force So we met with all of these lawyers and we talked about person-centered care and risk and choices and waivers and the lawyers said these waivers do not hold up in court The waivers are, can be viewed as coercive Waivers are not honoring choice and promoting person-centered care and they’re not the way to do it and the lawyers said to us, the way to do this is to come up with a shared decision-making process and that you clearly document the process and who is involved, you discuss the positive and negative consequences and there’s education, and that is documented And so we then expanded this task force to include many more professionals and called it a person-centered care planning task force because the lawyers said it’s all in the care planning, it’s not the waivers So you really shouldn’t be using waivers, you should be using a process like this and documenting the process So going back to the bathing example We’ve had some nice discussion about, you know, identifying her previous routines, whether she got assistance, what kind of a tub she had, and then some brainstorming about different alternatives that might be offered of just having somebody either assist her into and out of the tub or maybe be, you know, in the next room area behind a curtain whatever so that she has visual privacy, but there’s somebody there

You could also, you know, put in some walkie-talkies so that she can be monitored auditorally and if she needs help, she can call out and somebody, you know, is listening to it and can come you know and provide the assistance that she needs, but she’s still getting the sort of the real physical privacy And then it’s a matter of talking it over with her to decide which of those options are acceptable to her and that do serve to potentially mitigate some of the risk of slips and falls. I think we might be able to have time to go through one more example if you just want to talk through, we’ve only got five minutes left and I still need to go through a few slides and give people a sign out link Okay, Jen this is another diet-related one. I’ll let you So things like this are very common. People want to eat what they want to eat, they want to make their own choices about it They feel that they’re, you know, 80 years old and they’ve always eaten what they wanted to eat and they’re going to continue to do that whether we think it’s healthy or not So, you know, here’s an individual that just wants coffee and a few donuts in the morning and he loves to have dessert Doesn’t really, he’s not really big on eating meat, and he wants a couple of beers in the evening. So, this is a situation where you don’t say “Here sign a waiver, we’re not responsible for you anymore.” You say, “let’s sit down and talk about this Let’s find out was this his previous habit?” Maybe there were other things that he ate besides this that he would be willing to have included in his diet. And maybe the beers in the evening could be limited to a certain day? So it’s this, you know letting him enjoy the things that he likes, but perhaps steering him toward a healthier diet by compromising. And so this conversation with the person is important. Someone wrote in maybe if he was asked to be part of the meal preparation he’d be open to exploring different options. And I love that. That’s great. That’s a really great suggestion. Maybe there’s special recipes, you know, there’s particular food that he really enjoyed eating before and he’d like to be able to eat that again I think it’s also important for the community to recognize that they need to offer him alternatives because although he may say, you know, he wants a vegetarian diet, doesn’t want any meat, they need to offer vegetarian options not just sort of offer him turkey or a burger or you know meat at every meal if that’s really what he doesn’t want There are lots of other food options that are meatless that are more balanced and exploring those and I agree with Jen I like the meal preparation involvement to get him interested in that All right Katy, you have slides that you’d like me to skip to? Yeah, why don’t you advance? Right here. That’s perfect. So, hopefully you’ve all found these resources on our website, preferencebasedliving.com. If you go to preferencebasedliving.com and click on resources, you will see a link: honoring preferences when the choice involves risk. And as both Maggie and Jennifer mentioned, there is a training video that you can show at, you know for example, for education or staff development. The toolkit is there with both examples as well as blank templates and there’s also a shortened tip sheet version to sort of give you the 30,000 foot view. So if you’ll advance again for me So as I’ve mentioned this is part of our Preference Based Living series. We seek to create opportunities for providers to interact and learn from one another. We’d be honored to chat with you or visit your organization You can reach us, our project manager Alex Heppner, to schedule a time and go to the next slide please, and as always we greatly appreciate you joining us