We post an ethical or situational concern that has arisen in a facility where one of our readers works. It has no identifiers included. It gives you only the facts of the case. Then, you can respond to that concern. This is an ongoing dialogue, with comments added as they come in. In the following issue, assuming it has been resolved, we give you the outcome from the facility where the incident took place.

We are always looking for cases. Please send any cases that you would like considered for inclusion to: info@plainviews.org We will ensure that it is stripped of any identifiers. For further guidance about how to write up a CaseConference, please refer to the CaseConference Archives, Vol. 4, No. 3 "How to Submit a Case for CaseConference." (Click HERE)

We hope that this will help to inform not only those who are dealing with the issue, but will enable all of our readers to learn from the experiences and perhaps mistakes of others.

PLEASE NOTE: Due to unanticipated continuing responses to both the case and the resolution of the case, added responses can be viewed in the archives. Click HERE.

Case #25 (see below for responses)

A Caucasian woman in her 70's was admitted to a nursing home for rehab after knee surgery. Prior to the surgery, she had been independent; she was well educated and had full capacity. After her husband's death some years ago, her oldest son moved into her home. Soon after her arrival at the nursing home, he began barraged staff with phone calls and comments about the care his mother was receiving.

As part of standard admission procedure, the social worker discusses Advance Directives with a new resident. When there are concerns, the chaplain joins in this discussion.

In this instance, the social worker contacted the chaplain because the son would not allow his mother to complete the psycho-social assessment - he did it for her. When the social worker and chaplain visited the resident alone to ask her about her health care wishes, the resident stated that she could not complete any forms without her son there "because he is overprotective and would be terribly upset."

Before the son came into the room, the resident voiced that she wanted a DNR order; she had a nursing background and was clear about her choice. The son disagreed and the resident told him she would sign "whatever you want me to sign."

The chaplain and social worker agreed that the resident was not signing of her own free will. They also recognized that she would be returning home with this son shortly and that he was her only support.

The next day the social worker and the nurse spoke with the resident again and she willingly made out a new form that reflected her true wishes. This form was signed and witnessed and placed in her file, replacing the earlier form. When the resident was discharged, she took the newer form home with her. The son was irritated.

What should the chaplain's role be with the patient?

What should the chaplain's role be with the son?

What should the spiritual assessment of the patient include?

How should the chaplain work with the patient to address her pastoral care issues?

Responses:

This is an excellent case for our review because it is so illustrative of very typical daily family dynamics that confound health care professions in their attempts to serve the needs of their patients according to well established, and ethical policy and procedure. Patient autonomy and self determination would be at the top of the list of basic tenets regarding quality patient care. We have clear values and approaches to care that may not by reflected in the family dynamics of our patients.

In this case the woman and her son have been living as a nuclear family for several years. They have well established patterns of relating to each other. Though, it may well not be how we would choose to live, the question is not our own. It is hers.

A thorough verbal psycho-social assessment as well as an emotion/spiritual assessment should reveal if there is any need for intervention by adult protective agencies or by nursing home staff. If the son's overprotective behaviors are situational to this nursing home stay, then perhaps the chaplain can serve as a catalyst for illuminating and dispelling the concerns that are triggering the behaviors.

I would not initiate "assertiveness training" or any such thing unless the patient is not functional to her own satisfaction. We only need to look around our patient populations to realize that there are many less than optimal home situations. Our role is not to "fix" them all.

Stan Dunk, M.Div., BCC
Director of Pastoral Care
The Fort Hamilton Hospital
Hamilton, OH

Please check the archives below for comments made about previous CaseConferences.

Send your comments about CaseConference to info@PlainViews.org.