Ethics Quiz: When Dad Refuses Nursing Home Care
Ethics Quiz: When Dad Refuses Nursing Home Care
I invite you to read the following case and answer the quiz questions on the next page:
CASE VIGNETTE
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.”
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Further action should be taken to not only ensure his safety but to reduce the financial impact of his self neglect on 3rd party payers and society at large. His children are understandably reluctant to volunteer for more emotional abuse from this man so an outside entitiy must step in to protect him from his own "poor decisions." Civil committment or guardianship are logical avenues to persue.
Technically, the kids are neglecting their father, but they have really been estranged and are more victims than he is. I think it is time for the state to step in. The house needs to be seen by someone who can objectively assess the iving conditions and help decide whether the man can return there with more supports or not.
You also have either an option or a duty (varies by state) to recommend revocation of driver's license by the DMV.
I thought I joined this conversation some hours ago... illustrating basic aspects of handling such a dilemma ethically.
My comment has not appeard.
I wonder how long it takes as I have some more to add?
Eleanor Dawson
I am currently handling a relevant prodromal dilemma but don't expect it to get quite so so difficult. My husband is no intimidating reclusive narcissist; just a modest retired international air-navigator ex WW2 RAAF and RAF but can voice indignation.
Married 60 years to a non-medico, I find this loving and loved 89 yr-old has just passed the NSW Australia on-road test for driving to be told "nothing wrong come back in 2 years'. But he has notable short-term memory loss apparent daily now at home. Fortunately he has a mutually fond relationship with me and our three children in their fifties and is interested vaguely why they phone or drop in a bit more frequently nowadays to see how we are. Nice. A recent gall-bladder attack (no stones) gave us an opportunity for the first ever joint GP visit. It was privately contentious matter in advance but, when I was invited in to the consultation he readily gave approval for that to the GP. She had shown due respect to him when inviting me in. She had already heard brief mention from me earlier of concern re his memory. It gave the opportunity to bring up a matter of history not known to her from any of his solo visits for routine BP and BPH control. For at long intervals over the last 10 years he had he had lost consciousness briefly for a few minutes on six rare occasions. Ambulance ECGs twice had been normal. He was always seated and never fell or showed other signs. Once conscious he would firmly dismiss possible interest about cause and rationalised it. Now the GP has firmly advised him not to drive pending investigation and consultation. The first week's indignation and protest have now abated but there are repetitive questioning as to why he needs now to see the neurologist at all. Not clear if this is manly protest or actual failure to recall or even to comprehend. We do that next week complete with the results of the recently completed comprehensive investigations by Holter monitor, CT of brain and doppler ultrasound of vertebral and carotid arteries. When protest had declined to "just who's the boss?"I'd say...." two of us... the GP Dr K and me". "Why?" .... "Well you did encourage me into the St James Ethics Centre * traineeship for volunteering ethics couselling (from my Child and Adolescent psychitric practice) ( *cf Google). It is in the interests of all of us in the family and others to make sure we keep safe". My reply re Utilitarian Ethics seemed to hold no ice so next time I replied that it is "a family matter and our or GP has a solo 'family practice". Methods sometimes involve 'tough love'". I remind him too, that my mum, whom he fondly admired, would say to me in my childhood when things got tough "be as strong character, Bub"
Eleanor Dawson Sydney NSW
Unfortunately, the patient has reached the point that he is a danger to himself and others:
- A driving hazard
- Probably not taking his meds correctly.
- falling
- cooking (IE, possibility leaving the stove on)
- Unable to perform ADL's
-possibility of malnourishment
A legal guardian and the social work department should be able to work together to find a facility that can meet his needs and provide adequate oversight.
William Sorrells, RN
This is a common dilemma where, rather than rush to take away the client's rights in order to cover our own liability, we need to work on a plan, such as the slow introduction of a careplan that the client can comprehend and then be given the choice to work with one individual that he develops a trust (this can be done) in or choose to have an appointed caregiver in his home. Either way, his wish to stay in his own home should be reapected.
His driving should be definately addressed and his license not renewed if he is unable to 'follow the rules of the road'. Driving is a priviledge, not a right.
Speaking from a family's perspective, a male relative of mine was in a similar but much less severe situation. I was living 1200 miles away. This 89 year old male relative was fully oriented and still competent but irritable from a postherpetic neuralgia which he refused to take meds for. He fell at home for reasons unknown and was brought to hospital by ambulance. No cause was found and he persistently maintained he wanted to return home. The doctors opposed this on some sort of "ethical" ground, in view of his irritability as a sign of an undiagnosed psychiatric illness. They gave him 2 mg haldol IM twice. Then he developed neuroleptic malignant syndrome and died from it.
My relative was killed by the doctors' pretentions to ethics. This is a high cost for patients to bear. We are not gods and we must be humble about our skills and our outcomes. There are risks to patients just for remaining in the hospital, exposed to the vagaries of medications, hospital staff, and physicians.
In most states, you may notify DMV about impaired driving so they revoke the license.
no comment
Practically, how could you force him to accept more care? I could imagine that he would refuse to let care takers/aides into his home and presumably would attempt to elope from any unlocked alternate living situation.