Case Study 8-1: Whose Wishes Should Be Honored?
Mrs. Randle, a frail, 85-year-old woman who lives alone, is
admitted to a geropsychiatric unit because of irritability, confusion, and increasing incontinence. Mrs. Randle's family states she was continually refusing assistance from her home health aides and became angry when her family and home care nurses tried to reason with her about these refusals. During her hospital admission, Mrs. Randle is treated for a urinary tract infection, is hydrated with intravenous fluids, and two of her medications are adjusted. She subsequently becomes calm and cooperative with the care that she receives while in the hospital. When Registered Nurse Terry and a social worker talk with Mrs. Randle about the safety risks of her living in her home alone, she states, "I am 85 years old and think I should be able to decide how I want to live the rest of my life. I'm willing to take my chances. I will die if I go to a nursing home." Mrs. Randle often is unsure about the correct day of the week when questioned, yet she knows the name of the hospital and the reason she was admitted for treatment. She often is confused about the names of the hospital staff but is able to state her own name and the names of her children. Though Mrs. Randle agrees to cooperate with home care providers, her family continues to insist that Mrs. Randle be admitted to a long-term care facility. Her family asks the psychiatrist to complete the paperwork so a judge can have the patient declared incompetent. The psychiatrist does not usually seem sincerely interested in his patients, and he has spent little time with Mrs. Randle. This psychiatrist is usually willing to comply with most families' wishes. Terry and the unit social worker disagree with the decision to declare Mrs. Randle incompetent and are in favor of allowing her to return home with home care agency support as she wishes.
Review the chapter 8 content.
- Based on the information provided, does it seem that Mrs. Randle has decision-making capacity? What criteria can be used as a basis for your decision? What needs to be included in a full assessment of Mrs. Randle's decision-making capacity?
- Does safety at home for Mrs. Randle seem feasible? If so, how might this be accomplished? If not, why not?
- What could Terry and the social worker do to try to resolve the disagreement among the patient, her family, the doctor, and themselves?
- Is a form of paternalism being used by any of the people involved in this case? If so, is it a form of justified paternalism? Does the approach seem ethical? Why or why not?
- Which type of quality-of-life evaluation is most appropriate in this situation? Explain.
- How is the issue of Mrs. Randle's dignity involved in this case?
- How might the registered nurse and social worker enter into a discussion with Mrs. Randle about the meaning of her life? With her family? With the physician?