I have previously written about a patient on this site: “How elderly patients can be stubborn to their own detriment.” In that post, I discussed how the patient repeatedly turned down appropriate therapy for her hypertension, saying she didn’t need the help.  Now I’m writing an update.

Due to the patient’s refusal to accept treatment for her hypertension, despite counseling on the part of her cardiologist and primary care physician that she needed to be on a daily medication for it, she has now found herself in an unenviable place.  Fifteen years later, she is now dealing with the following medical conditions that are all a direct result of her untreated hypertension:

• congestive heart failure
• sick sinus syndrome with a need to eventually have a pacemaker put in
• open heart surgery to repair an aortic aneurysm, which ruptured on the OR table
• aortic valve insufficiency
• atrial fibrillation
• vascular dementia
• worsening of her variant angina

Fifteen years after refusing to comply with appropriate medical advice to begin taking one pill a day, she now finds herself confined to a secure nursing unit for patients who have end-stage vascular dementia due to neuropsychiatric symptoms.  Besides her cardiac medications, she is now on anti-anxiety and antipsychotic medications.  She will soon not know who her family members are, and has a life expectancy of about 6 to 12 months.

Due to her independence, stubbornness and unwillingness to take one blood pressure pill per day when she started having hypertension, this one decision has ended up putting her family members through grief and pain as they have watched her slow demise into nothingness.  Indeed she herself wanted to go back and change her decision regarding what she had done, but alas by the time she saw the error of her way it was already too late, as she was 4 to 5 years into her vascular dementia.

Once she reaches the point of where she doesn’t know who her family members are, and she is totally unable to take care of any of her personal needs, her pacemaker will be turned off and she will be allowed to die.  Her refusal to take that one pill a day so many years ago has been her undoing.

As her dementia worsened, her life, especially over the past five years, has been a slow decline, a slow shutting of the door.

When I compare what her life could have been like, to what it truly is, I am saddened.  I see so many healthy, vibrant 80 to 90-year-olds, patients who are enjoying life, spending time with their grandchildren and great-grandchildren, going on vacations.  Yes, I agree there are those patients in their 80 to 90s who are chronically ill and not doing well, but not all of them are this way.  Nor does dementia affect everyone in this age range, albeit it does affect a fair amount.

So my question is how can we learn to remember in our educating and counseling patients about their medical care to not only address the short-term effects of their not wanting to do appropriate medical care, but also remind our patients about the long-term consequences of their decision?  Each and every patient is different, but I know from my interactions with this one, had someone discussed with her how her hypertension would affect her brain and put her at risk for dementia, I know she would have listened and decided to begin taking that one pill a day.  Keeping her brain healthy was the most important thing to her, she once told me.

We need to try to remember in our counseling of patients to steer our counseling to that which motivates our patients to improve their lives, or like in this patient’s case, protect her brain.

Sharon Bahrych is a physician assistant who blogs at A PA View on Medicine.