Iatro-compliance: an unintended consequence of excessive autonomy in long term care facilities.

PURPOSE: Periodontal disease and caries remain the most prevalent preventable chronic diseases for seniors. Seniors transitioning into long term care facilities (LTCFs) often present with oral health challenges linked to systemic diseases, plaque control, psychomotor skills and oral health literacy. Many retain a discernible level of physical and cognitive ability, establishing considerable autonomy. This study examines the effect of autonomy on residents' ability to perform oral hygiene. METHODS: Descriptive data were developed utilizing mixed methodology on a convenience sample of 12 residents and 7 care staff of a LTCF. One-on-one interviews consisted of questions about demographics, and exploration of the influence of ageism, respect and time constraints on resident autonomy in oral care practices. RESULTS: Data suggests shortcomings, such as failure of the staff to ensure oral hygiene oversight and failure of the resident to ask for assistance. Autonomy, while laudable, was used by residents to resist staff assistance, partially motivated by residents' lack of confidence in care staff oral hygiene literacy and skills. In turn, by honoring resident's independence, the staff enabled excessive autonomy to occur creating an environment of iatro-compliance. CONCLUSION: While it is beneficial to encourage autonomy, oversight and education must remain an integral component of oral hygiene care in this population. Improved oral hygiene skills can be fostered in LTCFs by utilizing the current oral health care workforce. Registered dental hygienists (RDHs), under indirect supervision of a dentist, can fulfill the role of an oral health care director (OHCD) in LTCFs. A director's presence in a facility can decrease staff caused iatro-compliance and increase oral hygiene skills and literacy of the residents, while enhancing their autonomy through education and support.

Improving end-of-life care for patients with chronic obstructive pulmonary disease.

The provision and awareness of the need for end-of-life care has expanded greatly in the past decade. The burgeoning older adult population is obviously a factor in the growth of both hospice and palliative care organizations. Additionally, public awareness and healthcare literacy campaigns have called attention to the plight of those dying in pain. Healthcare professionals have stepped up their initiatives to educate both the patient and family members about the options available to them at the end of life, however many patients with chronic obstructive lung disease (COPD) still do not receive adequate palliation of symptoms. This article will highlight some of the issues related to end-of-life care for individuals diagnosed with COPD and offer suggestions on how better care can be implemented.

Medication adherence issues in patients treated for COPD.

Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%-60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient's selection of both the device and the regimen. Patient's health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

Incorporating geriatrics into the respiratory care curriculum.

The absolute number of adults over the age of 65 years is increasing nationwide and worldwide. Older adults today are more independent and self-sufficient than persons of that age were a generation ago. An increased incidence of acute and chronic disease results in relative morbidity but less mortality in those aged 65 years and older. The decision to incorporate or infuse education in geriatrics into existing respiratory care classes is not difficult. Implementation may be a little more challenging, but gradually adding geriatric components to courses over time is a perfectly reasonable way to introduce students to their future patient population. Fortunately, a growing number of elderly individuals desire to treat pathology rather than accept it as an inevitable consequence of aging. For these reasons, respiratory therapists have been brought into the realm of geriatric medicine, more by default than by organizational planning. The most passionate converts to the important role of geriatrics are physicians, nurses, and therapists who have recently attempted to shepherd their own aging parents through a health care system. If that experience that leads to these conversions could be measured and communicated, the world at large might be convinced of the value of education in geriatrics.

Care of the ventilator circuit and its relation to ventilator-associated pneumonia.

Ventilator circuits should not be changed routinely for infection control purposes. The maximum duration of time that circuits can be used safely is unknown. Evidence is lacking related to ventilator-associated pneumonia (VAP) and issues of heated versus unheated circuits, type of heated humidifier, method for filling the humidifier, and technique for clearing condensate from the ventilator circuit. Although the available evidence suggests a lower VAP rate with passive humidification than with active humidification, other issues related to the use of passive humidifiers (resistance, dead space volume, airway occlusion risk) preclude a recommendation for the general use of passive humidifiers. Passive humidifiers do not need to be changed daily for reasons on infection control or technical performance. They can be safely used for at least 48 hours, and with some patient populations some devices may be able to be used for periods of up to 1 week. The use of closed suction catheters should be considered part of VAP prevention strategy, and they do not need to be changed daily for infection control purposes. The maximum duration of time that closed suction catheters can be used safely is unknown. Clinicians caring for mechanically ventilated patients should be aware of risk factors for VAP (eg, nebulizer therapy, manual ventilation, and patient transport).