Stepping Up Levels of Care: When is the right time and who decides?
After reading the case, visitors are invited to share how one might approach this situation. There is a "Post a Comment" link at the bottom of this entry and you may use the questions for reflection at the end as prompts.
Lois, a gregarious, charming 88 year old woman, lives with her cat "Pancake" in a multi-unit dwelling. Lois, a widow for 16 yrs, never had children and has survived all of her siblings. Her only family are inlaws and cousins (all of whom are in their 80s/90s) living in Australia. In her younger days, Lois was a patron saint of wayward animals (and a few stray people) and has a life tenancy with Pancake in her current home. A life tenancy means that she owns the right to live in her home, but she does not own the property.
Lois is severely limited in her function due to a combination of severe kyphosis (curvature of the spine) and congestive heart failure, which leaves her breathless to walk across the room. Movement is quite difficult. Lois has long time friends who assist her with "big" grocery purchases. Lois has an electric wheelchair that enables her to go out to the pharmacy on a nearby street to purchase day to day groceries and sundries. Lois has an aide who comes for 3 hours a day, 6 days a week. Lois has neighbors who drop in to visit and make sure she eats as well as assist with occasional purchases.
Last week, Lois went out to the pharmacy and grocery store. After returning her electric wheelchair to its place in the garage, she began the walk to her front door, and almost collapsed about 1/2 way to the door. The incident frightened Lois and she waited for 20 minutes on the sidewalk until she had enough strength to get to her door. There isn't any place to put the wheelchair closer to her front door, though the property owner is accommodating to Lois and has offered to build a "house" for the wheelchair just outside Lois's front gate.
After a recent hospitalization following a fall, Lois required 24 hour care and in addition to her usual helper extending her hours. Another home aide stayed with her overnight. Lois is fiercely independent and prefers to care for others rather than being cared for, so that arrangement didn't last for more than the requisite 2 days to satisfy the discharge planners from the hospital. Thus, extended hours of assistance is not an option at this juncture.
Though she has a roof over her head, Lois has limited means to support herself. According to the neighbors who assist with her finances, she has enough money to support herself for one more year. Thus, suggestions to increase the hours of her helper are repeatedly rebuffed and she recently reduced the housekeeper from weekly to twice a month to manage her budget. Lois will not leave Pancake (the cat), and no care facility will take a cat. Further, she is extremely reluctant, even fearful, of leaving her apartment because it is the only "thing" that she has. With a life tenancy, she retains the right to live in the property until her death though she has no equity in the apartment. Given her limited resources, the housing solution presents an important asset for her and she intends to retain it as long as she possibly can.
The incident of getting back into the house has left Lois quite distressed. Her building neighbors are alarmed by the episode and by the increasing difficulty she has just moving around her house. At what point, might it be appropriate for neighbors and friends (who are also Durable Power of Attorney for Health) step in to oversee a transition to a stepped up level of care?
Questions for Reflection
How might one approach this situation?
What are the issues raised in this case?
Is this an ethical dilemma? If so, how would you articulate the ethical conflict?
Do you need any additional information? If so, what is it and why/how is that relevant?
What knowledge (ethical, legal, medical, philosophical) might be relevant for analyzing this case?
What framework might be appropriate to assist thinking through this case?
What might be a reasonable path forward? Are there multiple acceptable approaches?
How would each of the different perspectives justify their response?
Please leave comments, ideas, questions, and insights using the comments feature below. When you leave a comment, you may do so anonymously or with your name, but it would be very helpful if you indicated your role/discipline to assist clarifying your perspective. (RN, Geriatric care plan manager, family member, elder, caregiver, MD, MSW, Case manager, etc.)