When a patient won't accept help from family/support system

[AmericanChai]

I'm just a nursing student at this point (just got accepted into nursing school so no experience). I had a recent situation with two elderly family members that got me thinking about about how to delicately balance a person's emotional needs and trying to handle a medical crisis. In this case the family member is in her 80's and a bit senile. She had lost her appetite due to antibiotics after a minor skin surgery. Her husband, also in his 80's, would not push her to eat and drink, and so she lost a good amount of weight. 22 pounds in 21 days to be exact. She was not a big person to begin with. He waited for the followup surgeon's appt, assuming that the surgeon would address all her medical needs. The surgeon addressed the weight loss by recommending that she see her GP as soon as possible. The husband did not understand why a GP was needed, and did not make the appt, thinking still that the surgeon would handle all her needs. If the surgeon did not put her in the hospital, then he assumed she was still okay. I explained to him that the surgeon would only address the skin wound, and the GP would address her lack of appetite and weight loss. We all encouraged him strongly to take her to the ER or to the GP without delay. All attempts and offers for family to come there and help them (they are out of state but we have enough people willing and able to drive there to help) were refused with anger. The husband has become more combative and stubborn in his old age. He was not able to see the reason of taking her to the GP or ER. Nor could we speak to the GP ourselves about our concerns as we didn't know who he/she was, and it would probably violate some kind of privacy laws. The family argued over whether to respect their rights to choose their own actions vs. intervening and seeking medical care for the woman. Finally the husband himself saw that she was getting lethargic and took her to ER. She was very dehydrated and emaciated but is making a recovery now in the hospital.

The crisis is over, but it got me thinking-- you need to respect adults to make their own decisions but clearly when their decisions are not safe, at what point can someone step in and insist they seek medical help? I understand that sometimes the courts can award guardianship over people-- but that's not what our family wants at this time. When we tried to be advocates for them (offering to drive there and go to the doctor with them) they angrily refused our offer to the point that the woman's health was seriously compromised.

As health care professionals, how do you deal with this situation? I felt like my relative was slipping through the cracks through misunderstandings about the medical system, and age related mental states.

[heron, ASN, RN]

As long as an adult is legally competent, you cannot force treatment ... even if the proposed treatment is likely to be life-saving. Period.

If the next of kin or POA of the person needing treatment is the one making the decision, then you need to either get adult protective services involved or go to court to get guardianship.

As far as I know, the only illness that we are allowed to force treatment is tuberculosis (and maybe syphilis ... don't really know about that one, though)

[classicdame, MSN, EdD]

In a hospital setting I would confer with the case manager to determine if all possible avenues have been considered. They are more cognizant of state laws regarding these situations. Outside the hospital, the local health dept may need to be called - same as an abuse situation. If the patient was 8 instead of 80 what would you do???? Same process.

[classicdame, MSN, EdD]

another thing, in this episode you described it was not the patient refusing care. That too makes a difference.

[AmericanChai]

Lots to think about! It was not so much of a refusal of care as it was a misunderstanding of the medical system, and the elderly man being combative. In this case the man trusted the surgeon to treat both the wound and the lack of appetite, and that didn't happen. I think he was just thought it wasn't serious enough if "the doctor" (who can treat everything in his mind) didn't take action to address that problem.

When my daughter was sick as a baby/toddler it took a long time for me to understand the system-- what to see the GP for, what to see the surgeon for, what to see the GI for. If I went to the surgeon and mentioned that daughter was having more vomiting, he would refer me to the GI. THe GI would then say this is not related to her med condition, it's just a stomach flu- go see the GP.

In elderly people and those who are not savvy to the system, people can fall through the cracks. Is there any way to set up advocates for people so they understand how things work-- that the surgeon only treats the wound, etc? Also like in this example, the surgeon said to get an appt with the GP and the man never made that appt for his wife. The surgeon never followed up to make sure the appt had been made, and the GP was unaware of her condition until she ended up being admitted. It's just such a dangerous situation and I can totally see how the elderly can fall into this trap and have their health compromised over and over.

In the same light how do you know if elderly patients (who might have an equally elderly caregiver) are sticking to their med schedule and not mixing meds, or repeating doses because they forgot that they already took a med. It's just so dangerous, and having this family situation has really opened my eyes to how complex the needs are for the elderly.

[PAERRN20]

I would have called the Area Agency on Aging. They can get involved on a level that we cannot.

[SuesquatchRN, BSN, RN]

Frankly, the co-symptoms could have been easily addressed by the surgeon were he willing to a) take the 5 non-billable minutes of teaching the husband it would have taken, and b) given a good gosh darn. The weight loss was a DIRECT result of the surgery and recovery. For what part of that is he not responsible?

Really, is he so arrogant and above general medicine that he couldn't have paid a tad of attention to the entire dynamic?

[belgarion]

Really, is he so arrogant and above general medicine that he couldn't have paid a tad of attention to the entire dynamic?

Apparently so. Sounds like 80% of the surgeons I ever met. Cut em open, stitch em up, move on to the next and don't bother me anymore.

[PostOpPrincess, BSN, RN]

Frankly, the co-symptoms could have been easily addressed by the surgeon were he willing to a) take the 5 non-billable minutes of teaching the husband it would have taken, and b) given a good gosh darn. The weight loss was a DIRECT result of the surgery and recovery. For what part of that is he not responsible?

Really, is he so arrogant and above general medicine that he couldn't have paid a tad of attention to the entire dynamic?

Actually, he could be made liable if the family knew the right way to make it so...