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CaseConference #14 (Please scroll down for responses to this case)

A 94-year-old woman falls and breaks her hip. She is brought to the hospital and refuses surgery to repair her hip. Mrs. S has been an independent woman, who lives by herself, still drives and her ADL (Activities of Daily Living) level is very high. The staff, believing that she does not understand that she could return to her home and have a meaningful life after surgery and rehab, continually try to convince Mrs. S that she should have the surgery. Mrs. S keeps saying that she wants to go to a nursing home, be given adequate pain medication and allowed to die. Her 69-year-old daughter is furious at the staff for trying to "convince" her mother to have the surgery. She meets the chaplain in the hall and tells the chaplain what is going on. The chaplain, a member of the Ethics Committee, wonders if this should be referred to that Committee.

What is your role as chaplain in this situation?

How would you approach the patient?

How would you go about assessing this patient?

How would you deal with the staff?

What is your role with the daughter?

Should the chaplain suggest to the daughter that she ask for an Ethics Consult?

RESPONSES:

The case described of an active 94 year old who declines hip surgery and asks, apparently, for comfort care raises a few ethical and advocacy issues from a chaplaincy perspective. First, was a family meeting arranged and held with the patient, family, and medical team? This could help discern a) whether or not the patient is truly making an informed decision, and b) whether the family is respecting her wishes or trying to superimpose their own in their apparent reaction to the staff. Surgery is always risky with someone of such an advanced age, but a question I would have is does she (the patient) understand that, barring major complications, such a surgery would most likely enhance her comfort level in the long run?

Second, I would try to meet individually with the patient to assess whether she was, indeed, expressing her own wishes, or whether she felt pressured or coerced in some way by her daughter or other caregivers. If there was any question about her mental acuity or competency, I would suggest that the medical team request a psychiatric consult to assess competency. If she was not deemed mentally competent, then the decision-making for her healthcare would be handled by her durable power of attourney for healthcare, or if none had been named, to her next-of-kin, by default.

Third, before any surgery occurred or even a consult to the ethics committee, I would try to talk to the patient to see if she had discussed her treatment wishes with her daughter and doctors, AND if she had completed an advance directive- and specifically who she had named as her DPOA for healthcare. She may not even want her daughter involved in such decisions, so that would need to be determined before involving the daughter any further.

Fourth- regarding an ethics consultation- whether and at what point the ethics committee was consulted would depend on several factors - such as the organizational policy for consulting the committee, as well as the outcome of other interventions. At our organization, an ethics committee consultation is an option to be explored after other interventions have been attempted. Certainly, the patient, and daughter (if she is recognized as a DPOA), should be made aware of their right to an ethics consultation, and second opinion - both verbally and in writing. These interventions are all integral components of the advocacy side of chaplaincy, as I see it.

Rev. John Olsen, M.Div., B.C.C.
Staff Chaplain
Abington Memorial Hospital
Pastoral Care Department

The chaplain surely must be involved. I have been in a similar situation. Approach the patient in a way that lets her know you are her advocate but that you will be also making sure that all information has been provided to both physician and patient. It could be that the patient simply doesn't want surgery and is willing to live with the pain and discomfort, but I have found that to be rare. Assess if her refusal stems from something deeper than she is presenting to the medical staff. It turns out it my case, that the patient had a bad experience with doctors many years ago at another hospital. She also didn't want to be a
"weight" on her family. Chaplains need to be in on these conversations about fear and dependence. In my case the patient, by not having the surgery, ran the risk of her broken hip bone severing her common femoral artery. The chaplain in my opinion needs to encourage the staff to be patient. Frustration and anger from staff would only lead to less openness from the patient. Being on the Ethics committee myself, I had to make sure that the patient understood the doctors and that the
patient was making her decision based on good info and had every chance to refuse or accept the offer for surgery. I would inform the daughter that as a medical team, our physicians have a responsibility to make doubly sure that the patient is aware of all scenarios if patient refuses surgery and that we would never force surgery on anyone. In my hospital's case we planned family meetings and informed pt and family of risks. She decided to go ahead with the surgery and recovered successfully. It is my belief that she changed her mind because she was listened to and someone heard her fears resulting in her anxiety level subsiding. If the case presented is not soon reconciled one way or the other I would have someone call an ethics consult. I doubt, however, I would present that as an option to the daughter. If I thought there needed to be an ethics consult I would call for one and of course inform the patient and daughter.

Alan Wright, Chaplain
Baylor Medical Center at Irving

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