Modules

Complexities of care of the elderly

Part 1

 

Milly: Plainsview Health Centre, Milly speaking.

Penny: Hello Milly, it’s Penny Simons here, Jack McTeer’s daughter.

Milly: Oh, hello Mrs. Simons. How’s Jack doing?

Penny: I don’t know what’s going on, but he’s in bad shape. I was here three weeks ago and he seemed fine, but today he’s crying … not making sense, and the place is a mess. He won’t even get up from his chair. Can I bring him in to see Mr. Stevens?

Milly: Oh dear, that does sound concerning. I’m afraid that Mr. Stevens is out all day doing retirement home rounds. I think you’d better bring him to emergency at Thornbury Hospital. Are you able to get your father to the hospital or would you like me to arrange for an ambulance?

Penny: Ah … ah dear. Well okay. I think I can manage to get him there myself. Thanks.

Milly: Okay. Let me know if you need anything else.

Penny manages to bring her father to Thornbury Hospital and is about to meet Dr. Shah.

  • Dr. Shah: Hello, I’m Dr. Shah. Are you Mr. McTeer’s daughter?

    Penny: Yes, I’m Penny Simons and this is my father, Jack McTeer.

    Dr. Shah: Hello, Mr. McTeer.

    Dr. Shah: I understand that you’ve brought your dad to the emergency. Can you tell me about what has led to this?

    Penny: Ah. Well I saw him about three weeks ago, and he seemed pretty much as usual. I usually go in every two weeks, but I had to work last weekend. Today, when I got there his place was a mess … he wasn’t making any sense and when I tried to get him to tell what was wrong he just yelled at me.

    Dr. Shah: What was he like three weeks ago?

    Penny: Three weeks ago he seemed fine, he wasn’t confused. He lives alone and he’s not the easiest man to get along with — a stubborn old farmer. He was complaining about his renters, which is nothing new. I noticed he wouldn’t get up. Said his leg hurt. Well he still drives to the store and to the health clinic at Plainsview. I think he takes his medication. Today, his place was a mess, and as you can see he is not taking care of himself anymore. I’m really worried about him. I don’t know if he takes his medications but I’ve brought in all the bottles I could find.

    Dr. Shah: Okay. Hmm. I see he’s diabetic, he has high blood pressure and, some arthritis. Anything else?

    Penny: Not that I know of but, he doesn’t complain. You see I live about 100 kilometres away and I try to call and come to see him every couple of weeks on the weekends.

    Dr. Shah: You mentioned renters earlier?

    Penny: Yes. He doesn’t farm anymore. He has rented out all the land. That’s his major source of income.

    Dr. Shah: So he looks after his finances and his personal needs himself? There’s no one around regularly except you?

    Penny: No. No one. He keeps pretty much to himself but he’s never been like this before.

    Dr. Shah: Okay. Well let me have a look at him then I’ll come and talk to you.

    Dr. Shah: Mrs. Simons, I’ve taken a look at your father. He has an infected ulcer on his leg, which I think may be the source of all this and may account for his acute confusion. It’s not safe for him to return home. We will need to admit him, run some tests, and begin treatment. I will need to consult with an internist. When I suggested that to your father he seemed unable to appreciate the seriousness of his condition. He refused treatment. He just wants to go home. We will need to establish who the most appropriate decision-maker is. Are you his closest relative?

    Penny: I’m the only child. My mother has passed away so, I guess it’s up to me to make these decisions.

    Dr. Shah: I see.

Commentary

Communication problems are a major cause of complaint about health care among patients and family members. Not surprisingly, communication around consent and capacity is particularly important.

Think about this scene:
An unconscious patient is brought in by ambulance with no one accompanying them. The triage nurse obtains little information from the paramedics. Despite not being able to get the patient’s consent, the paramedics had started an IV. In such a situation, consent is implied due to the specific emergency context.

In Jack’s case, his daughter comes with him. While introducing himself to the patient, Dr. Shah quickly determines that he needs to get information from Jack’s daughter instead. The physician, however, does not ask Jack’s permission to get information from Penny, assuming that he would consent were he able to.

It is common practice for physicians to assume that a family member will act in the patient’s best interest. In this scene, has the need for a substitute decision-maker been adequately explored? What else could Dr. Shah have done to assess Jack’s current capacity, given that a full capacity assessment was not feasible in this situation? What would you do?

In these kinds of cases, physicians make assumptions all the time about consent, believing that the patient would agree if they were competent. Luckily, most of the time things work out. As we go through the module, think about Jack and his daughter’s relationship, unknown to Dr. Shah at the time, but later revealed. Penny provides a good deal of her father’s personal information, and agrees to his admission despite Jack’s objections.

Complete documentation, including reasons why certain decisions were made, is paramount in situations like this.

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Next: Part 2

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