Patty was admitted to an aged care service. She was 65yrs old and Australian born. Patty had recently had a stroke and also had significant end-stage cardiac disease. She was the mother of seven children, with four different fathers. She had been living in the community with a daughter prior to her stroke in a situation of both emotional and financial abuse. She had schooling until the age of 12yrs, and her relationships with partners had also been abusive. She was compliant, docile and accepting of all care without question.
Patty shared a room in the service with the same person for five years and they established a close friendship. Patty became increasingly more assertive and self-determining in the way she led her life over this 5 year period. She had several episodes of severe illness that led to hospitalization which she did not cope with very well, producing significant anxiety and psychological distress. Since her admission to the service she had re-established a relationship with her two sisters who would visit regularly and provide significant support to her. Patty granted her sisters her Enduring Power of Attorney. Patty did not have an Advanced Care Directive.
Patty’s roommate became very ill and died after a short illness. Approximately 2 months after the death of her long-term room-mate and friend, Patty began refusing nutrition, hydration and medication. She clearly articulated that she did not want to continue her life. She was increasingly in discomfort and her activity levels were severely compromised by her previous stroke and advanced heart disease. Patty was physically demonstrative of her decision, by closing her mouth tightly when food or fluids and medication were offered and turning her head away. She would respond appropriately to questions, but would not initiate conversation .She would smile spontaneously and converse when visited.
The initial concerns expressed by the medical practitioner were based on the potential for depression, related to the death of her friend. He was of the view this may have been part of the decision Patty was making and for her decision to be part of suicidal ideation. Increasingly Patty was becoming more distressed physically due to her untreated cardiac disease: very short of breath, marked fluid retention and severe limitations on her mobility. Her refusal of food and fluid was also causing adverse physical effects. Patty’s sisters were of the view that Patty had made her decision and did not want her wishes to be overruled. The nursing staff had formed a close relationship with Patty and found the situation distressing. However the staff realized the challenges with providing ongoing support for Patty would require invasive procedures, insertion of feeding tubes and medication by alternative routes. The nursing staff also knew that Patty’s prior experience of an acute care environment had caused significant anxiety and on one occasion she had refused transfer to hospital to manage her health needs. The nursing staff were also had the advantage of establishing a therapeutic relationship with Patty over a long period of time. The nursing staff were of the view that Patty had arrived 5 years earlier as a self-effacing quiet compliant resident and had increasingly asserted herself over the years to live her life by choices and her individual life-plan, albeit within the community of the service. Her moral personhood emerged as the determinant of how she led her life and the decision she was now making was an intentional and conscious choice.
A case conference of all stakeholders was convened to seek a way forward for resolving the divergent positions. It was decided to also seek additional assessment from an Old Age Psychiatrist.
1st June 2012 at 3 p.m.
In everyday health care, ethico-legal conflict can emerge. Drawing on the content of this unit, the literature, professional codes and standards provide a critical analysis of the case study.
Your discussion should include:
Identification of ethico-legal positions and concepts within the case study
Identification of consequences of decisions
Evaluation of the particular approaches to ethico-legal decision making
Application of ethico-legal principles to clinical decision making
Exploration of negotiated outcomes and alternative pathways to resolution