I invite you to read the following case and answer the quiz questions on the next page:
Mr H, aged 87 years, is admitted to an acute care ward of a general hospital with uncontrolled hypertension, delirium, and cellulitis. His medical problems respond to fluids, antihypertensives, and antibiotics, with a gradual clearing of mentation on the third hospital day. As his medical condition improves, Mr H becomes increasing irritable and demanding, especially with nursing staff. The medical team is concerned that Mr H has some underlying cognitive impairment.
A geriatric psychiatrist is called to see Mr H. Bedside cognitive screening suggests moderate dementia that has exacerbated premorbid narcissistic personality traits reflected in Mr H’s constant dissatisfaction with his care and abuse of nursing staff.
Mr H lives alone and refuses to discuss the possibility that he may need a higher level of care. Attempts to provide home health assistance and even referrals to Adult Protective Services have failed because Mr H refuses to let anyone into his home. He will not let even his children into his house, so no one is sure how unhygienic the conditions really may be.
Mr H’s physical therapists believe he has been falling and that he cannot possibly drive safely, yet he continues to get behind the wheel. An occupational therapy evaluation indicates that Mr H is not able to perform many of the instrumental activities of daily living. Formal assessment of decisional capacity determines that Mr H lacks sufficient ability to reason regarding the risks of refusing more supervision or of appreciating his own cognitive and self-care deficits.
The medical team and geriatric psychiatrist are concerned that nonadherence to medications and inability to make follow-up appointments have contributed to Mr H’s hospitalization. Social work is contacted for assistance. Social workers find that Mr H has 6 offspring who have long been the recipients of his emotional abuse. The children readily admit that they are traumatized and fearful of confronting their father with his incapacity or constraining him to accept a more appropriate disposition.
After much discussion, one of the children agrees to serve as a surrogate decision-maker but Mr H rejects the recommendation that he complete an advance directive formally designating a health care agent. The children have the financial wherewithal to pursue guardianship, but not the strength of will to confront their father. Educated and successful individuals, the children seem to understand that their father can no longer make his own decisions, but they continue to defer to him for medical and disposition decisions stating, “whatever he wants to do.” They accept that they may one day find him seriously ill or even dead in his home but insist he has the right to make what they acknowledge is a “bad choice.”