Determining a resident’s goals of care and understanding their wishes and preferences for care is an entrusted responsibility of all practitioners. Anticipating that goals of care frequently change over an illness trajectory is crucial. These changes need to be acknowledged and incorporated into the plan of care to ensure that care is patient centered. Currently there is no nation-wide or state database for persons to document their wishes or preferences for care. At this time many states have the POLST (Physician Orders for Life-Sustaining Treatment ) [1] or the MOLST (Medical Orders for Life-Sustaining Treatment ) [2] that can be used to document patient wishes on the use (or not) of CPR, intubation, feeding tubes, IV therapy and antibiotics. Most states also have laws pertaining to the use of advance directives on health care such as a living will or durable power of attorney, which can further enable patients to document their wishes and preferences for care (see Chapter “Ethical and Legal Issues” for further discussion).

Providing quality medical and nursing care is more complex than writing a “do not resuscitate” or “full code” order. Practitioners and staff should meet with patients and family to review their expectations on admission to a facility or program and to establish goals of care. Periodic follow-up meetings are often necessary as illness progresses and crises occur that will necessitate modification of the goals of care. For example, if a patient has dysphagia and needs an altered diet with thickened liquids, a discussion about aspiration and feeding tubes is vital (see Chapter “Weight and Nutrition” for further discussion). If a patient is admitted with severe COPD, then a discussion on CPR and respirators is needed.

Most people appreciate the opportunity to discuss end-of-life care and have often had previous experiences with friends or other family members that will influence their thoughts and decisions. Listening to the stories of the resident and their family can provide that health care team invaluable information on their beliefs and values, which will assist the team with providing the care that they desire. Suggesting a palliative care approach can often help facilitate difficult conversations focusing on goals of care and treatment at end of life. Documenting these conversations in the resident’s medical record will support the staff in providing goal directed patient-centered care as the patient’s condition progresses.

Falls are an all too common event in long-term care. Falls are potentially life threatening and can result in fractures, particularly of the hip or pelvis, as well as brain trauma. An increasing percentage of residents are taking anticoagulants and their risk of serious bleeding (especially intracranial) is increased when a fall occurs. Between 50 and 75 % of residents in NFs fall each year, and many fall more than once (“frequent fallers”). Ten to twenty percent of NF falls cause serious injuries and up to 6 % of these falls result in fractures. The CDC reports that nursing home residents account for 20 % of deaths from falls in the over 65 age group, even though only 5 % of people over 65 live in nursing facilities. In the USA alone about 1800 people living in NFs die each year from a fall [3].

The 2010 AGS Clinical Practice Guideline: “Prevention of Falls in Older Persons” has excellent recommendations on the screening and assessment of patients at increased risk of falls or who have fallen [4]. All patients should be questioned about a history of falls and the circumstances surrounding those falls. A multifactorial risk assessment should be completed as well as a physical exam that includes a gait and balance evaluation. A focused history about falls, all medications being taken (including OTC medications), and relevant risk factors should be included in a multifactorial fall risk assessment. Relevant risk factors include: diabetic neuropathy, urinary urge incontinence, multiple antihypertensive medications, and depression on psychotropic medications.

When performing the Physical Examination assessing gait, balance, mobility, and lower extremity joint stability and function is important. Neurologic function including cognition, peripheral nerves, proprioception, reflexes, cortical, extrapyramidal and cerebellar function, as well as muscle strength of the lower extremities should all be included. Cardiovascular assessment should include heart rate and rhythm, orthostatic blood pressure and peripheral pulses, and possibly carotid sinus stimulation. Test visual acuity and check feet and footwear. The Functional Assessment should include an assessment of ADLs and adaptive equipment including mobility aids. Query about fear of falling and any self-imposed limitations due to that fear. An Environmental Assessment should be done to check for lighting, obstacles, uneven surfaces, and other hazards, especially in community dwelling elderly.

Recommendations to decrease fall risk include:

Residents with cognitive impairment may be impulsive and unable to remember information they are taught on fall prevention. Frequent monitoring and regular toileting may decrease but not eliminate their risk of falls.

Bed and chair alarms do not prevent falls; they only alert staff to a resident who is trying to stand or get out of bed. Restraints should be avoided at all times (both chemical and physical) because they do not prevent falls [7]. The use of side rails is controversial, with double rails considered a restraint. Many side rail injuries are linked to older beds, which allowed entrapment of the patient in the rails. There is a risk that a patient will climb over the side rail and fall from a higher height and thus suffer an even more severe impact injury than without the rail [5]. Not only are hip pads usually not acceptable to patients, but also they have been shown to have minimal efficacy [6]. Most nursing facilities now have “fall teams” or a falls protocol to evaluate each fall and to determine what preventive interventions to initiate like the use of low bed. Input by the practitioner can be vital due to the practitioner’s ability to take into account risk factors (intrinsic and extrinsic), patient multi-morbidities, and guide the interdisciplinary term to create a plan of care to lessen fall risk. The medication review performed by the practitioner often plays a critical role in reducing falls [8].

Currently recommended vaccines for the elderly population include the influenza vaccine, pneumococcal vaccine (Pneumovax and Prevnar 13), and herpes zoster vaccine (Zostavax). The Prevnar 13 had only been administered to children, but as of 2015 it has been recommended and covered (by Medicare) for adults age 65 and older. Because immunosenescence can diminish the antibody response to vaccines and thus vaccine efficacy, research continues on the development of vaccines with higher efficacy [15].