24. CASE: Changing Care and Care-Giving

Kevin Henderson is an 83-year old man who is hospitalized in an internal medicine clinical unit at the local hospital. Kevin has a variety of serious medical conditions including severe Alzheimer’s disease, diabetes, coronary artery disease and advanced chronic obstructive lung disease. He is slowly recovering from a difficult-to-treat pneumonia, which required treatment with intravenous antibiotics.

During this admission, the clinical unit nurses and attending physician are having a difficult time communicating with Kevin. On some occasions, he appears to recognize his wife and children and speaks a few, seemingly appropriate, words to them.

Family members make regular visits to the hospital. Mr. Henderson’s wife, Nancy, has osteoarthritis that has been increasingly disabling of late. She is somewhat shy and tends to defer her decision-making to her eldest son, Peter. He lives in Toronto and usually visits home twice yearly. He has recently flown to Halifax to see his father and provide psychological support to his mother. Peter has power of attorney for his father’s financial matters.

There are two other children, Sandra and Paulette, who live in Dartmouth. They are estranged from their brother due to unresolved, significant conflict that arose from the sale of the family cottage two years ago.

When out of hospital, Kevin lives with Nancy at home in a rural area, where he is totally dependent on his family and visiting VON nurses. Nancy has been finding it increasingly difficult to care for her husband at home. She arranges to meet with her children in the clinical unit’s family room to discuss alternate living arrangements for Kevin. When they meet, Nancy states that she is not willing to make a decision about placing Kevin in a continuing care home on her own. She then looks to Peter to begin the discussion.

An advance/personal directive has not been made. Kevin, who was in denial during the early stages of his dementia, avoided talking to his family about his wishes for his care when his health condition got worse. Sandra recalls that while her father was well, he had once commented to her that he did not want to end up in a nursing home at the end of his life.

  • What ethics concerns should the family be considering as they seek a way forward?
  • Who should be making decisions about Kevin’s care?
  • How would you help to facilitate this discussion?
  • Should Nancy’s health and well-being be considered equally as Kevin’s?

Some Values and Ethics Issues to Consider

  • Capacity
  • Substitute decision-making
  • Patient-family relationships
  • Respect for patient autonomy
  • Advance care planning and personal directives
  • End-of-life decision-making

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