Modules

Complexities of care of the elderly

Part 5

In this scene, Jack is meeting with Dr. Ormerod, the consultant psychiatrist.

This is not Jack’s first visit with Dr. Ormerod. This is a subsequent visit after Dr. Ormerod has determined that Jack is oriented, has no deficits in short-term memory, and understands why a psychiatrist has been asked to see him.

 

  • Dr. Ormerod: Ah, Mr. McTeer, please have a seat.

    Jack: Fine, well. Leave me alone. Just sit down. Sit down! … Alright.

    Dr. Ormerod: Okay. So, Mr. McTeer, what did you and your daughter talk about when she was last here?

    Jack: Ah she was bugging me to get that operation and I finally said yes to her just to get her off my back, but I really don’t want to do it. What can I do with just one leg? I won’t be able to look after myself or anything.

    Dr. Ormerod: How about you tell me a little bit about how things were before you came to the hospital.

    Jack: Well I’m alright, ah, except umm, I hadn’t been sleeping well and I seem to have lost a few pounds but, it’s not serious, I’m okay doc … I … you know … except I don’t have much interest in going out and doing other things. Lately I just don’t seem to have much energy.

    Dr. Ormerod: It appears things have been getting more difficult for you recently. Are you feeling pressured into making this decision? I understand you had given consent, and you are now having second thoughts. Did you sign the form?

    Jack: Penny put on the form that I said yes, but she signed it.

    Dr. Ormerod: Ah ha. Do you understand what could happen if you don’t have the operation?

    Jack: I’m going to die. It’s going to happen anyway.

    Dr. Ormerod: Yes, it comes to us all. How do you feel about dying?

    Jack: Well hell nobody wants to die unless they’re crazy. But what can I do? I live alone. Sure Penny comes to help me from time to time but she doesn’t really want to do it. I’m just a burden to her.

    Dr. Ormerod: Has she said that? I got the impression she was quite concerned about you, and that the two of you had discussed about finding another place for you to live in. One with more support.

    Jack: Like this place? I’ve lived in that house all my life. It’s all I know, and it’s all I want to know.

    Dr. Ormerod: So, if you did go ahead with the operation, and went home with some additional help, how do you see yourself managing say — with your finances, or getting food?

    Jack: Well exactly. I need to be able to drive to the bank and how can I drive with just one leg? And I don’t want somebody in my house telling me what to do!

    Dr. Ormerod: Many people function quite well after an amputation, including driving. I know the surgeon has told you what would happen afterwards. You will need some rehabilitation, and definitely some help. At least for a while. Have you thought about what the surgeon had to say, Mr. McTeer?

    Jack: I understand all that. I just don’t want to think about it.

    Dr. Ormerod: But you have to, Mr. McTeer. At some point in the near future, you will have to make a decision. Think about it some more, and if it’s okay with you, I’ll come back tomorrow and we can talk again.

Commentary

Dr. Ormerod has been asked to interview Jack to determine if he is possibly clinically depressed. There are circumstances in which depression can render a person incompetent to make some decisions, especially important ones like the possibility of death. From what you know of the conversation, does Jack want to die? “Not wanting to think about it” is a common and reasonable response. Do you think Jack is clinically depressed, and therefore incompetent to make this decision? What is the “reasonable person standard”?

Dr. Ormerod has given Jack more information about the operation and subsequent recovery. Is there any other information that you think Jack should have to help him make an informed decision?

Resources

Reflective exercise 3

Dr. Ormerod's consultation note

“I saw Mr. McTeer in consultation today, concerning his competence to give consent or refuse an amputation for a potentially gangrenous leg. I found him discouraged, and appropriately so, given the circumstances. I do not feel he meets criteria for clinical diagnosis of depression, which would interfere with his understanding of his medical situation. Notably, Mr. McTeer seems ambivalent and is easily influenced (particularly by his daughter). Reference has been made to some tension in their relationship, which may render the previous consent invalid. This will need to be clarified with the daughter expeditiously.

Based on my assessment of Mr. McTeer today, I find him competent to make medical decisions. He will, however, need more information about the services available and his post-op functioning to allow him to make a truly informed decision.

I will be happy to participate in the discharge planning, specifically around competence and capacity.

Dr. P. Ormerod”


 

Next: Part 6, version 1

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