Case Study: Dementia
John Beauford is a 77-year-old divorced male. He moved to Florida after his divorce and has no contact with his former wife. He has no children, and his only sister lives in a distant state. They talk weekly on the phone but have not seen each other in several years. He attends church and volunteers at a community organization. He has several acquaintances but no close friends. Recently he has become increasingly forgetful but passes it off as a sign of aging. He is staying home alone more and more frequently, and often cannot remember whether he ate. He missed several meetings at the community agency because he forgot. When someone from the agency called him about his absence, he became angry and defensive, stating nobody told him there was a meeting. While driving home from church one day on a route he had taken numerous times, he became disoriented and lost. Trying to find his way home, he drove for more than 2 hours, failed to notice a traffic light, and was involved in a motor vehicle collision. He is transported to the emergency department of the closest hospital. He is unable to answer questions about his health history and becomes belligerent when different staff members ask him the same questions. However, he does not have life-threatening injuries, only some minor contusions. The emergency department staff find his driver’s license and Medicare card in his wallet, but no health information is available. There are business cards from the community agency. There is no information about Mr. Beauford in the computer system of the medical center. The healthcare team needs more information about his health history, current medications, allergies, and emergency contact(s). A computerized tomography (CT) scan of the head shows no head injury that would explain his behavior. A psychiatrist and social worker are consulted.
Discussion Questions
- How can the healthcare team obtain necessary information without breaching confidentiality?
- What are some ways the healthcare team can use to attempt to establish a trusting relationship with Mr. Beauford?
- Use a formal ethical decision-making process to determine what should be done regarding Mr. Beauford’s case and eventual discharge.
- How can the healthcare team obtain necessary information without breaching confidentiality?
To obtain necessary information about Mr. Beauford’s health history, current medications, allergies, and emergency contacts without breaching confidentiality, the healthcare team can take the following steps:
a. Contact the community agency: Since there are business cards from the community agency in Mr. Beauford’s wallet, the healthcare team can reach out to the agency to see if they have any records or contacts for him. They can explain the situation and request any available information.
b. Contact his sister: Mr. Beauford’s sister, with whom he has regular phone contact, may have information about his medical history, medications, and emergency contacts. The healthcare team can ask him if he is willing to provide contact information for his sister and request her assistance.
c. Seek consent for information sharing: If Mr. Beauford is not in a state of medical incapacity and is capable of providing informed consent, the healthcare team can explain the situation to him and request his permission to access his medical records, contact his healthcare providers, or share information with his sister or the community agency.
d. Review any available legal documents: If Mr. Beauford has a healthcare proxy, advance directives, or a power of attorney for healthcare, these documents may provide guidance on who can access his medical information and make decisions on his behalf.
e. Explore any local or state laws: Depending on local or state laws, there may be provisions for accessing medical information in cases where the patient’s capacity is in question or when there are concerns about their safety. The healthcare team should consult legal experts or ethics committees if needed.
- What are some ways the healthcare team can use to attempt to establish a trusting relationship with Mr. Beauford?
Establishing trust with Mr. Beauford is crucial to providing him with the necessary care and support. Here are some ways the healthcare team can build trust:
a. Be patient and empathetic: Understand that Mr. Beauford may be scared, confused, or frustrated due to his condition. Approach him with patience and empathy, acknowledging his feelings and concerns.
b. Use effective communication: Communicate clearly and at a pace that he can understand. Avoid using medical jargon and complex language. Listen actively to his concerns and questions.
c. Involve a familiar face: If Mr. Beauford has an acquaintance from his church or the community agency, consider involving that person to help establish trust and comfort.
d. Offer reassurance: Assure Mr. Beauford that the healthcare team is there to help and support him. Explain their role and the purpose of the assessments and treatments.
e. Respect his autonomy: Whenever possible, involve Mr. Beauford in decision-making regarding his care. Provide choices when appropriate to maintain his sense of control.
f. Build rapport: Spend time getting to know him as an individual, learning about his interests, hobbies, and life history. This can help create a more personal connection.
g. Involve a social worker or counselor: A social worker or counselor can play a crucial role in building trust by providing emotional support and helping Mr. Beauford navigate the healthcare system.
- Use a formal ethical decision-making process to determine what should be done regarding Mr. Beauford’s case and eventual discharge.
An ethical decision-making process involves several steps to consider the best course of action for Mr. Beauford’s case and eventual discharge:
a. Identify the ethical dilemma: The dilemma in this case revolves around Mr. Beauford’s capacity to provide essential health information, his safety, and the need to respect his autonomy while ensuring his well-being.
b. Gather information: Collect all available information, including his medical condition, cognitive impairment, and social support.
c. Identify relevant ethical principles: The key principles at play include autonomy (respecting Mr. Beauford’s choices), beneficence (acting in his best interest), and non-maleficence (avoiding harm). Balancing these principles is essential.
d. Explore alternative courses of action: Consider different options, such as obtaining consent for accessing medical records, involving his sister or community agency, or seeking a legal evaluation of capacity.
e. Evaluate the alternatives: Assess the benefits, risks, and potential consequences of each option in terms of Mr. Beauford’s health, safety, and autonomy.
f. Make a decision: After careful deliberation, the healthcare team should make a decision that prioritizes Mr. Beauford’s well-being while respecting his autonomy to the extent possible.
g. Implement the decision: Take action based on the chosen course of action, whether it involves involving his sister, obtaining consent, or seeking legal guidance.
h. Evaluate the decision: Continuously assess the decision’s effectiveness and adapt the plan as needed to ensure Mr. Beauford’s safety and well-being.
i. Document the process: Thoroughly document the ethical decision-making process, including the rationale behind the chosen course of action, in Mr. Beauford’s medical records.
Throughout this process, it is essential for the healthcare team to prioritize Mr. Beauford’s best interests while respecting his autonomy and dignity. Consulting with ethics committees or experts in geriatric care may also be valuable in complex cases like this one.