11.3 Choice, Refusal, Advance Directives, and Grievances
Key Takeaways
- Residents may refuse any care or treatment; the STNA stops, documents nothing beyond reporting, and tells the nurse.
- An advance directive such as a living will or DNR (Do Not Resuscitate) order directs care; the STNA must know the resident's code status before an emergency.
- Residents have the right to file grievances and to be free from retaliation for complaining.
- Personal choice covers food, clothing, schedule, activities, roommates, and visitors, not just medical care.
11.3 Choice, Refusal, Advance Directives, and Grievances
This cluster of rights is about self-determination: the resident, not the staff, controls their own life and care. The STNA's job is to support the choice and report to the nurse, never to override it.
The right to make choices
Freedom of choice is broad. Residents decide:
- Food: what to eat, substitutions, snack times, religious or cultural diets.
- Clothing and appearance: what to wear, how their hair is styled.
- Schedule: when to get up, bathe, and sleep.
- Social life: which activities to attend, who visits, roommate concerns.
- Providers and care: which treatments to accept or decline.
When a resident's choice conflicts with the care plan (for example, refusing a low-salt food), you honor the choice in the moment and report it so the team can adjust the plan.
The right to refuse treatment
A competent resident, or one with a legal representative, may refuse any treatment, medication, meal, or procedure. The correct STNA sequence is:
- Stop the activity immediately.
- Respect the refusal without arguing or shaming.
- Try a different approach later if appropriate (rephrase, offer choices, change timing).
- Report the refusal to the nurse so it is documented and followed up.
Advance directives and code status
An advance directive is a legal document stating the resident's wishes if they cannot speak for themselves.
| Document | Meaning |
|---|---|
| Living will | States which life-sustaining treatments the resident wants or refuses |
| DNR (Do Not Resuscitate) | A physician order: do not start CPR if the heart or breathing stops |
| Durable power of attorney for health care | Names a person to make medical decisions for the resident |
You must know each resident's code status before an emergency. If a resident has a valid DNR and stops breathing, you do not begin CPR. If there is no DNR, you start CPR and call for help. Never guess; check the care plan or ask the nurse at the start of your shift.
Grievances and freedom from retaliation
Residents have the right to voice complaints about care, food, staff, or conditions, and the facility must respond. Crucially, residents are protected from retaliation, no one may punish a resident for complaining. As an STNA, if a resident complains to you, listen, do not take it personally, and report it through the chain so it reaches the nurse or administrator. Residents may also complain to the Long-Term Care Ombudsman (Ohio statewide line 1-800-282-1206), an independent advocate.
Common traps
- Coaxing a refusing resident until they give in, persuasion that becomes pressure is a rights violation.
- Starting CPR on a resident with a documented DNR. The order legally directs you not to.
- Treating a complaint as a personal insult or warning the resident not to report, both violate the no-retaliation rule.
The STNA's role: report, do not decide
A recurring theme across self-determination items is that the aide supports and reports; the resident or their representative decides, and the nurse and team document and adjust the plan. You are an advocate and an observer, not a decision-maker over the resident's life. When a choice or refusal could affect the resident's health, your value is in reporting it accurately and promptly so the clinical team can respond, not in talking the resident out of it.
Documenting and reporting a refusal
When a resident refuses care, the nurse needs specific facts to update the care plan. Give an objective report:
| Report element | Example |
|---|---|
| What was refused | "Mr. Lopez refused his morning shower" |
| What you observed | "He said he was too tired and wanted to rest" |
| What you tried | "I offered a bed bath instead and to return after breakfast" |
| The outcome | "He still declined; I will reapproach this afternoon" |
Keep your report objective and factual, no opinions, no labels like "difficult" or "non-compliant." Those words are both disrespectful and clinically useless.
Code status: know it before you need it
The DNR scenario is one of the highest-stakes items in this domain because the consequences are immediate and irreversible. At the start of every shift, confirm the code status of each resident in your assignment. If you do not know whether a resident has a DNR, ask the nurse before an emergency, not during one. In a real arrest with no DNR on file, you start CPR and call for help; with a valid DNR, you do not start CPR and you summon the nurse. There is no version of the answer where you stand by deciding on your own or where you wait for family to weigh in during the emergency.
Putting choice and safety together
Sometimes a choice carries risk, a resident wants to walk without help, or eats food against a prescribed diet. The exam answer is rarely "forbid it" and rarely "ignore the risk." It is usually "honor the choice as far as it is the resident's right, keep the environment safe, and report to the nurse so the team can educate the resident and adjust the plan." That balance, respecting autonomy while reporting risk, is the heart of resident-centered care.
A resident is found unresponsive and not breathing. The STNA confirms the care plan shows a valid DNR (Do Not Resuscitate) order. The aide should:
A resident complains loudly that the food is always cold. The STNA should: