THE ETHICAL DILEMMA

The Ethical Dilemma



The Ethical Dilemma: When a Patient Refuses Medical/Nursing Care

INTRODUCTION

The patient says, 'I don't trust hospitals and I don't want strangers in my home!'-how should clinicians respond?

Since her husband's death eight months ago, Mary Rosario, an 80-year-old African American woman, has lived alone in their apartment. (This case is a composite based on our experiences.) Her landlady and Janet Hale, a deceased friend's daughter, are concerned about her declining health. Because Ms. Rosario has no known family, they contact Adult Protective Services, which asks the geriatrics department of the local medical center to perform a medical evaluation. When Paula Bayliss, MD, and Ruby Alvarez, RN, arrive, they're met downstairs by the landlady and Ms. Hale, who explain their concerns: "Since Ed passed, Mary's lost a lot of weight. She forgets things and falls a lot. She doesn't keep herself clean like she used to." They report that she's refused offers to take her for medical care. Ms. Hale adds, "She tells me, 'You have enough to do with your own family-I don't want to be a burden.'"

Ms. Rosario permits Dr. Bayliss and Ms. Alvarez to enter her apartment, where they note signs of personal and environmental neglect that appear to be fairly recent; for example, although seasonal clothing is neatly stored, the apartment smells of urine and rotting food and Ms. Rosario is disheveled and wearing stained clothing. She moves unsteadily, holding onto furniture as she returns to her chair.

Ms. Rosario agrees to answer some assessment questions and allows a limited physical examination. Although her answers are appropriate, she frequently repeats herself, and becomes teary when her husband is mentioned. She reports feeling "very unhappy" and says she hasn't felt like grooming or cleaning the apartment since he died. Mealtimes are irregular. Asked about her physical condition, she states that she has "a sore area on my chest" and is "always tired and sometimes dizzy." She hasn't seen a physician in many years. She reports "having the aches" in her left hip and knee. Asked why she hasn't sought medical care, she explains, "I'm afraid they'll put me in the hospital-I don't trust hospitals." When Ms. Alvarez suggests home care, Ms. Rosario replies, "I don't want strangers in my home. I can manage."

Initially reluctant to remove her blouse for the physical examination, Ms. Rosario allows Ms. Alvarez to wrap a towel around her to lessen her exposure. On examination a large, hard mass on her left breast is noted. Ms. Rosario says she thinks she might have cancer. Her heartbeat is irregular; atrial fibrillation is suspected. The team agrees that Ms. Rosario's condition warrants further evaluation (and possible hospital admission), including an in-depth assessment of her cognitive and functional status and examination by oncology and cardiology specialists. Dr. Bayliss tells her, "I'd like you to see these specialists because there might be treatments that can make you more comfortable." But Ms. Rosario refuses: "It's a free country, and I can care for ...