Any short answer questions were not scored. To enhance your learning, annotated answers for all questions are provided below.
A 75 year old man, your patient, lives alone in his own home.He has been managing fairly well at home and he is able to make his own decisions regarding his healthcare.A friend has been helping him with some tasks such as filling medications, shopping and housecleaning.The friend has been borrowing the older man’s car for errands and has started to borrow/use items without permission.Family members have noticed this and have asked the patient to not let the man into the home.The patient is reluctant to do this, as he states that “this man is my friend, and friends lend things to each other.”What is your next step in assessing the situation?
A. Ask the patient Questions from the Elder Abuse Suspicion Index (EASI).
B. Contact the Department on Aging to alert them to the possibility of elder abuse.
C. Complete a cognitive evaluation to assess whether the patient has dementia.
D Interview the family members for further information.
Answer: A. Ask the patient Questions from the Elder Abuse Suspicion Index (EASI). The patient is at risk for abuse. Your next step is to more fully interview the patient to better assess what may be occurring. Asking questions from the Elder Abuse Suspicion Index can be helpful in obtaining further information and is the next best step. Family members may also provide helpful information and speaking with them (after being granted permission by the patient) is appropriate. A cognitive evaluation may provide further information about the patient but would not answer the question as to whether the patient is being abused. The Department on Aging investigates elder abuse however, a referral to this agency may occur after more information is obtained.
In the above case, your evaluation of the patient’s cognition shows that he is quite clear in his cognition and has a good understanding of his medical issues.You believe that he has medical decision making capacity, and thus is able to make medical decisions surrounding his care.While he does rely on his friend for shopping and banking and he does feel that he needs to “go along with” various suggestions of his friend, he does not wish to contact the Department on Aging.As his physician, what is your next step?
A. Call psychiatry for further evaluation of his mood and cognition.
B. Contact the Department on Aging and report your concerns.
C. Encourage the patient to contact the Department on Aging.
D. Petition the court to implement a court appointed guardian.
Answer: C. Encourage the patient to contact the Department on Aging. Your concern is that the patient is being abused and coerced. Encouraging the patient to contact the Department on Aging is the next best step. Given that the patient is decisional in his cognition you should abide by his wishes but encourage him to make steps to protect himself. Petitioning the court is not appropriate unless the patient is non-decisional in regards to his care and needs court intervention for protection. The Department on Aging cannot intervene if a decisional patient does not want their services.
A 90 year old woman lives has lived with her two adult children for the past 20 years.The patient has severe dementia, and is only able to say a few words.She has had multiple hospitalizations for urinary tract infections, dehydration and delirium.The medical team recommends hospice care for the patient.The patient’s children, who are her “Power of Attorneys for Health Care”, state that their mother always told them that she “wanted everything done” in her health care.They decline the option of hospice, against the advice of the medical team, and would like their mother to be in the ICU for aggressive medical care of her now occurring urosepsis.In this case, your next step is to:
A. Instruct the social worker to contact the Department on Aging for issues of neglect.
B. Institute the care plan as the family wishes, on a trial basis with continued education.
C. Consult the hospital ethics team to determine whether the patient is being abused.
D. Transition the patient’s care to a “comfort care” model by invoking futility of care.
Answer B. Institute the care plan as the family wishes, on a trial basis with continued education. The patient’s children state that their mother’s wishes are for full care. In light of no information to the contrary (living will, advance directives), arguing against this is usually not productive. Proceeding with the more aggressive care plan and then working to build rapport and trust with the family and increase education is the next best approach. Ethics team consultation can be helpful in clarifying goals and may be used if the initial approach is not effective or the patient’s family and medical team continue to experience conflict in care goals and approach.