Fragments of a Resident in Long Term Care
How Residents Are Made Present in Medication Decisions
Most medication decisions in long-term care don’t happen in front of the resident—they happen in staff-only spaces, through paperwork, memory, and conversation. In these moments, the resident is “present” only through stand-ins and substitutions: a chart note, a lab result, a nurse’s recollection, or even a gesture that mirrors their symptoms. This is not a sign of individual neglect—it’s a feature of how the system is built. Long-term care runs on routines that absorb every decision into their timetable, shaping not just what is possible but what is imaginable. And until those structures change, routine will keep eating ideals for lunch every single day.
There’s a management cliché that says, “Culture eats strategy for breakfast.” Spend enough time in a long-term care facility and you see its clinical cousin: Routine eats ideals for lunch.
By “ideals,” I mean the lofty visions we put and see in policy statements across all organizations and staff training slides: shared decision-making, patient-centered care, active participation. These are valuable aspirations. But on the ground, they meet the friction of the everyday—shift changes, med pass schedules, missing paperwork, staff absences. And in those spaces where decisions actually get made, these ideals often morph into something else: pragmatic adaptations to fit the day’s constraints.
One example is the repetitive character of how Doctor Day unfolds on the various floors. It’s a fixed point in the week when a physician, nurse, and sometimes others gather in the nurses’ room to review medication charts, discuss symptoms, and make changes. The nurses’ room itself is locked behind a keypad—a small but important detail. This is a staff-only space, the backstage of care. And here, in the hum of conversation, the resident whose medications are under discussion is often not there in person.
This absence is not necessarily the result of neglect. It is built into the architecture, the timetable, and the habits of the place. The resident is present, but through other means—paper, memory, and conversation. This is what I call the mediated resident.
Routine eats ideals for lunch.
The Mediated Resident
In cases I’ve written about before—Ativan and Teva—the resident’s presence in the decision-making process was entirely mediated. Their story came into the room through chart entries, verbal reports from care aides, and the recollections of staff who had interacted with them days or weeks earlier.
These fragments were treated as sufficient to act upon. A nurse might say, “She’s been more settled since last week,” referring to an interaction in the hallway. A care aide’s note about increased confusion might prompt a dose adjustment. The resident’s own voice—the kind of direct, unfiltered account that patient-centered care advocates call for—was missing.
One moment stands out. A nurse, describing what she believed were the resident’s withdrawal symptoms, saying, “I had these spells.” It was a bodily act of empathy, a merging of her own sensory memory with the imagined experience of the resident. The substitution was powerful—it conveyed urgency and familiarity—but it was still a substitution.
In these conversations, the resident becomes an assemblage of traces: the MAR (Medication Administration Record), a lab report, an anecdote from a hallway encounter. None of these pieces are false, but together they form a composite that is partial, stitched together to be actionable in the moment.
The resident is there—but mostly as an assemblage of paper, memory, and mimicry.
Substitution and Stand-Ins
The stand-ins are not only verbal or gestural—they are also material. The MAR, for example, is a portable, trusted object. It is an authoritative proxy for the resident’s medication history, daily dosing, and recent changes. Staff move it from desk to desk, passing it between hands, consulting it as if it were the resident’s own testimony.
Lab results, printed or pulled up on a computer screen, add another layer. They might confirm a suspected side effect or push the team toward a medication change. In either case, the lab value stands in for the resident’s lived state.
Even the memory of a past event—“remember how she reacted to that antibiotic last year?”—becomes part of the composite. These pieces are mobilised in the room as though they are equivalent to direct presence.
This method of knowing is not careless. It is careful within the constraints of time and space. But it is also revealing: in long-term care, to “know” a resident often means to assemble a usable profile from fragments. It is a craft of patchwork knowledge.
The MAR is more than a chart—it’s a portable and the current most accurate medication version of the resident.
The Spatial Politics of Decision-Making
The nurses’ room is more than just a physical location. It is an access-controlled zone that shapes the boundaries of participation. The keypad on the door is not simply a privacy measure—it enforces a distinction between those who are inside the decision-making process and those who are outside it.
Once inside, the talk is different. Staff speak in shorthand, surmise freely, and sometimes joke. It’s the kind of conversation that doesn’t happen in hallways or at bedside. The resident is present in these conversations only through the proxies already mentioned.
The fact that decisions are made here, rather than in a resident’s room or in a shared space, has consequences. It reinforces the idea that the work of deciding is backstage work—something to be completed and then delivered as a finished product to the resident. When the decision emerges “onstage” in the form of a pill cup or a new order in the MAR, the process that led to it is invisible.
This spatial arrangement is efficient in some ways—it keeps discussions private, allows for quick reference to charts and forms—but it also means that residents are rarely in the position to influence the discussion as it unfolds.
Time, Displaced
Many medication discussions are temporally displaced. The symptoms under review may have occurred weeks earlier; the lab results might be from last week; the most recent verbal report could be from yesterday’s shift. The decision being made is therefore about a version of the resident that is already slightly out of date.
This time lag is not unusual in institutional life. Records take time to compile; shifts change; not all staff work every day. But it has a particular effect in long-term care: even if the intent is to respond to a resident’s current needs, the decision is often shaped by the echoes of their recent past.
When these temporal displacements align—when a lab result matches a verbal report and a chart entry—they can create a strong case for action. But when they don’t, staff must decide which fragment to trust most. And that decision, too, is shaped by habit, hierarchy, and personal judgment.
The “As-If” Resident
Sometimes, staff bridge the gap by speaking in the resident’s imagined voice. “She’d say no to that,” someone might remark. Or, “He wouldn’t like the side effects.” This practice is more than a convenience—it’s a way of keeping the resident “in the room” without actually bringing them in.
It’s also a form of advocacy. By voicing what they believe the resident would want, staff aim to preserve a sense of agency. But it’s agency by proxy. And like all proxies, it depends on how well the stand-in matches the real person’s views and experiences.
These “as-if” moments are pragmatic. They allow the conversation to move forward without rearranging the physical or temporal setup of the meeting. But they also highlight how unusual it would be, in this setting, to have the actual resident weigh in directly.
Affect in the Absence
Affective language and gestures weave through these conversations. “She’s been doing so well lately.” “He’s been a bit off.” These impressions, though informal, can carry as much weight as lab values. They are treated as legitimate indicators of how a resident is doing.
The nurse’s ‘spells’ in the Ativan case is one example of affect crossing into technical talk. It’s a way of collapsing the gap between the resident’s absent body and the decision-maker’s present one.
Emotions circulate alongside data points. They may not be officially recorded, but they are part of the decision-making economy—powerful, persuasive, and woven into the institutional rhythm.
Polypharmacy as a Collective Accomplishment
These observations point to a larger truth: polypharmacy in long-term care is a collective accomplishment. No single person makes the decision. It emerges from the interplay of nurses, pharmacists, care aides, labs, forms, schedules, delivery systems—and the resident, whose presence is refracted through all these intermediaries.
The absence of the resident from the room is not an oversight. It is an outcome of how the system is designed to work. Knowing without being with is not an accident; it’s a feature of the organizational rhythm.
Routine eats ideals for lunch
It’s a quiet truth of long-term care—the one that rarely makes it into policy documents or conference keynotes. In here, the cycle holds — routine eats ideals for lunch every single day. Shifts, med passes, and scheduled reviews pull every decision and conversation into their rhythm. The structure doesn’t just shape what’s possible; it shapes what’s thinkable.
If we want to understand polypharmacy as it actually happens, we have to look closely at the patterns of mediated presence, substitution, and temporal displacement. These patterns don’t reveal individual failings; they expose the deeper logics embedded in the system.
The challenge, then, is not simply to call for more direct resident involvement. It’s to reimagine the spatial, temporal, and procedural structures that make that involvement so rare in the first place. Without changing the shape of the table—who sits at it, where it’s placed, and when it’s set—the mediated resident will remain the norm.