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Saturday, November 22, 2014

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Difficult ethical decisions

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One of my favourite teaching activities whenever I visit Israel is a workshop with the staff of the geriatric and rehabilitation unit at Ichilov Medical Center in Tel Aviv.

I have previously taught in the unit, which is headed by Dr. Yaffa Lerman, a geriatrician. I enjoy the workshops, which focus on complex ethical issues.

I decided to try to do this workshop in Hebrew, which I had been brushing up on. It was a bit of a challenge for me, but with patience and good humour and the occasional correction of my fractured grammar and vocabulary by workshop participants, I succeeded, thus adding to my enjoyment of the session.

The case we discussed could just as easily have been presented at Baycrest, which has a large elderly Holocaust-survivor population.

The patient was a female survivor in her late 80s, who had before her admission been living on her own in an apartment in Tel Aviv, apparently “managing” her “normal” activities. There was a question of the patient’s claim by some neighbours and her one estranged son, who had, in fact, not seen her in the previous two years and did not visit her while she was hospitalized.

Some weeks before the woman had fallen off a ladder in her apartment while arranging something on a high kitchen cabinet, and when discovered, she had been on the floor for many hours. She was admitted to the geriatric rehabilitation unit with some non-surgical fractures and underwent intensive mobilizing rehabilitation.

Investigations revealed evidence that she’d had a small stroke, which may have been instrumental in her fall, but most importantly, the patient had some degree of cognitive impairment – not enough for a diagnosis of true dementia, but there was sufficient evidence to raise the question of her mental capacity for complex decision-making, including whether she could return home and be independent, which was her wish.

The ethical conflict was that the staff believed her mental deficiencies were sufficient to require help if she were to return home, while she was absolutely set against any help in her home. In the recent past, under different circumstances, she had refused the involvement of community geriatric workers and she said she would reject them in the future.

The woman refused to consider moving into an assisted-living facility and was determined to return to independent living, which she believed she could do. Her mental and cognitive condition improved by objective measurements from the time of her admission to the medical centre, as did her function, but the staff had serious doubts about whether she would be safe at home alone.

Her son from Canada felt that she should not go home, but he did not have authority as a health-care proxy. In fact, at the point of the discussion, it was not clear if she could be declared incompetent, which would mean her decisions would be referred to a government-agency-appointed substitute decision-maker.

The workshop ended with the conundrum unresolved. Despite their concerns, none of the staff wanted to deprive the woman of her autonomy. The plan was to try to convince her to agree to some help at home on a temporary basis, to ensure that she was safe, and therefore avoid the need to consider removing her decision-making rights.

This case and the staff’s dilemma reminded me how universal such conundrums are and how important careful deliberation is before such difficult decisions are made.

 

 Dr. Michael Gordon is medical program director of palliative care at Baycrest. His latest book is Late-Stage Dementia, Promoting Comfort, Compassion and Care. His previous book, Moments that Matter: Cases in Ethical Eldercare, follows his memoir, Brooklyn Beginnings: A Geriatrician’s Odyssey. All can be researched at his website: http://www.drmichaelgordon.com.

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