Long term care

Six Things Physicians and Patients Should Question

Released January 18, 2017; Last updated January 18, 2017


Don’t send the frail resident of a nursing home to the hospital, unless their urgent comfort and medical needs cannot be met in their care home.

Transfers to hospital for assessment and treatment of a change in condition have become customary. However, they are often of uncertain benefit, and may result in increased morbidity. In one Canadian study, 47% of hospitalizations were considered avoidable, while a recent US study found 39% to be ‘potentially avoidable’. Transfer often results in long periods in an unfamiliar and stressful environment for the patient. Other hazards include delirium, hospital acquired infections, medication side effects, lack of sleep, and rapid loss of muscle strength while bedridden. Harms often outweigh benefits. Residents assessed and treated at their care home will receive more individualized care, better comfort and end of life care. If a transfer is unavoidable, give clear prior instructions to the hospital of the patient’s needs. Respect for patient choice is a fundamental consideration in all decisions to transfer to a hospital. A clear understanding of the patient’s goals must be established taking into account current health status, values and preferences. This will reduce the likelihood of inappropriate transfer. These goals should be discussed earlier and often with the patient and family, including whether comfort, function and quality of life are their most important goals.


Don’t use antipsychotics as first choice to treat behavioural and psychological symptoms of dementia.

People with dementia can sometimes be disruptive, behaving aggressively and resisting personal care. There is often a reason for the behaviour (pain, for example) and identifying and addressing the causes can make drug treatment unnecessary. When drug treatment is chosen, antipsychotic medicines are often prescribed, but they provide limited benefit and can cause serious harm, including premature death. These medications should be limited to cases where non-drug measures have already been tried and failed and the patients are a threat to themselves or others. When an antipsychotic has been prescribed, frequent review and attempts at reduction or discontinuation must be done to reduce harm.


Don’t do a urine dip or urine culture unless there are clear signs and symptoms of a urinary tract infection (UTI).

Unless there are UTI symptoms such as urinary discomfort, abdominal/back pain, frequency, urgency or fever, testing should not be done. Testing often shows bacteria in the urine, with as many as 50% of those tested showing bacteria present in the absence of localizing symptoms to the genitourinary tract. Over-testing and treating asymptomatic bacteriuria with antibiotics leads to increased risk of diarrhea and infection with Clostridium difficile. Overuse of antibiotics contributes to increasing antibiotic-resistant organisms.


Don’t insert a feeding tube in individuals with advanced dementia. Instead, assist the resident to eat.

Inserting a feeding tube does not prolong or improve quality of life in patients with advanced dementia. If the resident has been declining in health with recurrent and progressive illnesses, they may be nearing the end of their life and will not benefit from feeding tube placement. Feeding tubes are often placed because of fears that patients may aspirate food or become malnourished. Studies show that tube feeding does not make the patient more comfortable or reduce suffering. Tube feeding may cause fluid overload, diarrhea, abdominal pain and discomfort/injury (from the tube itself). A tube can actually increase the risk of aspiration and aspiration pneumonia. Helping people eat, rather than tube feeding, is a better way to feed patients who have advanced dementia and feeding difficulties.


Don’t continue or add long-term medications unless there is an appropriate indication and a reasonable expectation of benefit in the individual patient.

Long-term medications should be discontinued if they are no longer needed (e.g., heartburn drugs, antihypertensives) as they can reduce the resident’s quality of life while having little value for a frail elder with limited life expectancy (e.g., statins, osteoporosis drugs). Prescribing medications to meet lab test “targets” that apply to adults living in the community (e.g., blood sugar, blood pressure) may instead have dangerous effects on mobility, function, mortality and quality of life when applied to a frail elder in care.


Don’t order screening or routine chronic disease testing just because a blood draw is being done.

Unless you are sure treatment can be given that would add to quality of life, don’t do these tests. “Routine” testing may lead to harmful over-treatment in frail residents nearing the end of their life and lead to misusing healthcare resources that would do more good used wisely.

How the list was created

The Long Term Care Medical Directors Association of Canada (LTCMDAC) established its Top 6 recommendations under the leadership of their Director. LTCMDAC members were invited to participate in the list development by email. Two physician volunteers came forward to join the Director and form the Choosing Wisely Canada working group. To represent the patient voice, an articulate patient leader and Patients for Patient Safety Canada “champion” joined the working group. The American Medical Directors Association and Canadian Geriatric Society lists were reviewed as a starting point. None of these lists was specific to the frail elderly in residential care. The process aimed for recommendations that were valid and relevant for Canadian patients and our health care system. By small group discussion amongst the working group, the 6 recommendations were proposed. The document was then circulated to the members of the Board of the LTCMDAC for feedback and approval.



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