Beyond the Medication Pass: Attitudes, Ethics, Agency, and Antipsychotic Medications in Assisted Living/Residential Care

Abstract Background and Objectives As-needed (PRN) antipsychotic medication use (APU) among assisted living/residential care (AL/RC) residents is a controversial health policy issue. AL/RC care staff, families, clinicians, researchers, and policymakers disagree about PRN APU to manage behavioral expressions associated with residents’ dementia or cognitive impairment. Research Design and Methods Semistructured interviews among eleven direct care staff (n = 3), licensed nurses (n = 2), administrators/executive directors (n = 4), and consultant pharmacists (n = 2) currently working in Oregon AL/RC. Using situational analysis, we identify, describe, and visualize positions and ideologies by job role to theorize PRN APU decision-making. Results Three broad processes underlie APU to manage residents’ behavioral expressions: justifying PRN APU, moralizing APU, and balancing local practices (eg, managing behavioral expressions, respecting individuals) with nonlocal practices (eg, professional authority). People involved in the situation of APU in AL/RC describe positive and negative justifications, and personal moral positions that frame PRN antipsychotics or nonpharmaceutical interventions as “right” or “wrong,” driving various approaches to behavior management. Participants described a converse orientation between perceived level of agency within and proximity to the situation of APU. Those most closely involved, or local, to the situation of passing medications (eg, direct care staff and nurses) expressed less agency compared with nonlocal physicians and policymakers, who are not involved in the day-to-day practices within AL/RC. Discussion and Implications This study raises practice and policy implications regarding APU in AL/RC settings. Care staff roles, ethical considerations, and perceived agency inform decision-making on whether to use antipsychotic medications. Participants described costs and benefits associated with both PRN APU and nonpharmaceutical interventions when responding to AL/RC residents’ behavioral expressions. Participants’ experiences emphasize the interactions across multiple levels of care. Balancing regulatory goals with resident-centered practices underscores the need for a system-level perspective, extending beyond direct care staff passing antipsychotic medications to residents.