In a 2023 study, researchers explored the medical needs of elderly, mentally deficient individuals who lived alone. A common comment by interviewed physicians was that they knew some patients required greater supervision or care, but they acceded to patient choices to return home. Are clinicians placing too great an emphasis on competency and patient rights rather than on patient well-being?
Everyone knows the phrase: “First, do no harm.” Yet today, deciding what is harmful can be challenging. Many medications, for example, have severe and even deadly side effects. Are these considered when drugs are prescribed? Does this depend on the likelihood of occurrence, and if so, what frequency of occurrence is necessary to make this decision?
Actually, the patient defines seriousness, and a clinician discharges his/her ethical duty by informing the patient, verbally and in writing, about all side effects at or above a determined level. Yet, suppose a clinician is aware that a patient cannot manage his/her own care or understand necessary information but discharges the patient home solely based on patient preference. In that case, s/he has possibly endangered the patient’s life—a greater potential harm than limiting free will.
Years ago, I participated in an incident that involved an elderly woman with moderate Alzheimer’s and COPD. She used oxygen (O2) for the latter, and before hospitalization for an exacerbation of her COPD, she had a cart to move her O2 cylinder about her apartment. To make her life easier, respiratory therapy planned to send her home with a 25 ft. nasal cannula so that she could move about her dwelling without the cart. I advised against this, as I knew from the many hours I had spent with her that she would be unable to manage this lengthy tubing. The hospitalist claimed that she chose to go home and gave no credence to my concerns. She was found the next morning by her housekeeper, entangled in the tubing on the floor, where she had suffocated. Did she even know she was dying?
How did the hospitalist assume competency, given her level of dementia? Why had he not requested a mental status assessment (MSA) early in her hospitalization or relied on my observational and neuropsychological evaluations that had been requested by an agency for possible placement in assisted living? The MSA could have resulted in a competency hearing to appoint a guardian. The hospitalist’s behavior resulted from the common misconception that patient autonomy was a given, regardless of mental status. This is an error that is even made by experienced mental health professionals!
However, given the fragmented nature of health and social services, there is little a clinician or anyone else can do on a short-term basis to provide necessary assistance. Multiple agencies must be involved, each with its protocols and procedures, its turf and power to protect, and none structured to act expediently or for cooperation. Both research and reality have shown that an appropriate placement, despite its urgency, commonly takes months to process. Thus, if a clinician is impeded from necessary action, does this absolve him/her of unethical behavior? This depends on what efforts were made and how timely s/he made them.
Would not a patient’s mental deficiency be in his/her record, ascertained, or at least suspected quickly? This could be influenced by the questions asked, as some of these patients can initially present as normal if asked only basic questions. It is only over time that cognitive deficiency, especially when minimal, may become apparent. Nursing staff will likely identify minimal impairment first, which should be reported to the treating physician rather than only noted in the chart. The clinician should request a competency assessment as quickly as possible to allow time for evaluation before discharge. Although this will still be too brief to provide needed services, necessary agencies would be alerted to a patient’s needs, and home visits may be possible before judicial consideration of competency and subsequent actions.
Nothing original is necessary to alleviate this sluggishness, as the solution has been known and recommended for decades. Workers need to leave their silos and cooperate to expedite necessary arrangements for high-risk individuals, an approach that has been demonstrated to be effective. I know that every agency has large caseloads, and workers are strained, but if a patient is deemed high-risk, s/he should not be treated as a routine new client, as frequently can and does occur. For example, in another instance, an individual required a specific medication he could not afford for a degenerative lung disease. Despite it being indicated that additional damage accumulated daily by his attending physician, it took six weeks for funding to be approved, which resulted in additional lung deterioration that shortened his life.
A cooperative, local, cross-disciplinary committee would need to be established, and depending on regulations, state government may have to be involved. This committee would define what constitutes elevated risk and what actions could be expedited, circumvented, or delayed; develop procedures to accelerate these actions; and prevent abuse of the process. This is not simple, as I know from experience, but it is necessary to provide needed services and save lives.
M. Bennet Broner is a medical ethicist.
