Monday, 28 April 2008

Medical Care

I looked after a chap in his home, with his wife, through much of last year. Notionally he was depressed, but he seemed much more jaded and despondent than clinically depressed, to my reckoning. I saw him at intervals, roughly once every three weeks or so, throughout the Autumn and Winter. His GP asked for help, since the chap wasn't eating or drinking much, was largely bed bound and seemed to be fading away. He's got a good GP who works hard for his patients so I'm always happy to go the extra mile (or 6.8 miles in this case) to help out.

He refused all medication but I'm stubborn so a nurse and I visited every few weeks. He didn't want us to. We got him eating and drinking again. We got him more mobile. He no longer needed his frail wife to carry him to the toilet. He no longer wanted to die. He was no longer chain smoking in bed and burning his sheets/smouldering holes in the carpet. He still didn't want us to visit. By now, 6 months on, with him coping well enough and no evidence of mental illness and telling us to go away, I didn't feel we could keep intruding in to his home and persuade him How It Had To Be any more.

I knew it wouldn't go well.

Once when I saw him he was too breathless to finish sentences and his lips were a glorious shade of puce. Focal signs in his chest. GP tried to arrange admission but he'd not go in. The GP tried this a lot. He always said no.

Earlier this year things broke down. He became confused, wouldn't listen to his wife, didn't appreciate who she was or what she was trying to do, wouldn't accept help from his son or daughter, absolutely refused to go in to hospital. The GP was desperate. The GP asked if I could admit him. I visited the chap, saw a scene of woe, he was thoroughly confused which was just sufficient to persuade an Approved Social Worker to take the pink form the GP and I'd hastily penned and apply for him to be detained under section 2 of the Mental Health Act 1983 for admission and assessment on one of my wards.

Within a couple days on a cephalosporin he improved. Temperature, tachypnoea, dyspnoea, cyanosis, all better. Too, he was less confused. But still too frail to mobilise. Pretty infirm, really. Abdominal masses. Abnormal LFTs. Chest signs. Blood count that's halved in 6 months. Anorexia. Trophic changes of his skin with widespread pressure sores on admission (that are getting better now he's on the right sort of matress and nurses are attending to this). CT imaging is awaited. I suspect something sinister and have said exactly that to his family, along with words like "cancer" so we're all crystal clear we're looking for stuff that's not dysthymia or an adjustment disorder.

Meeting with family, we're all clear his mental health is the last thing that's concerning us now. But when his confusion's resolved and he's no longer detainable under the MHA 1983, he'll not accept informal admission. Saying that, he's too frail to self discharge and flounce out.

What to do, what to do . . .


Jobbing Doctor said...

This was a very thought provoking story. Your role has been pivotal in this man's last year. However, if he is not detainable under the MHA, then he has the right to discharge himself.

You have done a great deal, and you are working closely with the family and will probably have to hand back care to the GP.

He may die without a diagnosis. That is his right, and we should respect that.

Shrink Wrapped said...

Tricky. On the one hand, if he has capacity, it is his choice and his right to refuse medical intervention. But if it were my grandfather, I would be livid if you left it there.

I am interested in what his reasons are and why he is refusing treatment. There must be some underlying anxiety or something that is stopping him. Will he tell you? Do any of his family members have any ideas?

But tricky tricky tricky. I don't envy your position. Such a sad story.

Anonymous said...

As so often happens wth your tails of those you come into contact with I have been stopped in my tracks.

It is a tricky situation indeed and I would not like to be in your position just now. So many complex moral issues going on there.

Seratonin said...

I don't know but maybe deep down he has figured it out that he is seriously ill & just wants to give up & die.

Cat said...

The Mental Capacity Act would be a little more flexible compared to the Mental Health Act. Does he understand the repercussions of his decision not to seek treatment? That's one of the checks related to the Capacity Assessment. Ultimately though, if he's able to make his decision then the dilemma shouldn't be anyones except his own and his families (that might sound a bit heartless).

If I had a penny for each time I wanted to stop someone making a choice that I thought was wrong, I'd be much richer!

As for being too frail to leave, that is a practicality but it might also be a deprivation of liberty - for all the different that that might make in a practical sense..

Anonymous said...

Sadly, yet wisely, it is for this very reasoning and dilemma that the MHA and Capacity Act exist. They are not merely administrative documents to allow us to stride paternalistic into peoples lives based on our own judgments, but are there to safeguard the autonomous rights of the person.

I'm critical of how you assess him as confused on the basis he wouldn't listen to his wife - or was this just my misreading the context? ;o)
I'm more picky with the admission that you prescribed physical treatments, for conditions not considered to cause mental illness, whilst under the MHA - stretching the application of the law - tho I empathise with the juxtaposition with family etc.

A difficult social issue undoubtedly but one in which I uphold the principles of a right to choose.

Would you assess his decision to ignore everyone as being made in soundness of mind and out of dogmatic personality? And even if he is being consumed by mental derangement - would his current attitude be out of character with his pre-morbid nature?

Most old duffers do not want to burden others with their ailing selves and we still have remnants of those who feel when it is time to go it is time to go.

Shrink Wrapped said...
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