Clinical Ethics Committee case 5: Should we discharge our vulnerable patient to a family who seem unable to look after her?

Abstract

Referral to the Clinical Ethics Committee: A 55 year-old woman with Alzheimer’s Disease Mrs. A is 55 years old and suffers from Alzheimer’s Disease. She has had to take early retirement from her job at the checkout in a local supermarket on ill health grounds. She normally lives with her 56 year old husband and two adult children but she was recently admitted to the assessment ward of the psychiatric hospital following concerns on the part of her mental health social worker that she was not receiving adequate help and care at home from her family. Mrs A had been found wandering away from her house in the early hours of the morning by the police and had appeared unkempt and frightened. When she had been returned home, after her name and address had been found in her coat pocket, the family had been unaware of her absence and seemed unconcerned. The social worker had suggested a period of further assessment and respite to the family, which they were keen to take up, during which further discussions could take place to ascertain what further help could be offered. During the assessment in hospital, Mrs A continually asked to go home and made attempts to leave the ward on a couple of occasions but was easily persuaded to stay. A consultant psychiatrist felt that she lacked capacity to make an informed decision to go home as she was unable to retain information for a period sufficient to “weigh it in the balance”. She believed she had small children at home, whom she needed to look after and to bring home from school. She was disorientated in time and place and, although she had immediate recall for three words, she could not remember them after a few minutes. She was unable to copy a diagram correctly or write a sentence. She needed help with washing and dressing and often became incontinent of urine if not reminded to go to the toilet at regular intervals. An assessment of her social circumstances took place at Mrs. A’s home with her social worker and the occupational therapist. The house was poorly furnished and dirty. There were several hazards with regard to steps and stairs. A great many empty beer and whisky bottles were lying around in the living room and kitchen. A financial assessment revealed that Mrs. A’s Disability Living Allowance (DLA) and other benefits, such as Mr. A’s carer’s allowance were making up a good proportion of the family’s income. Her husband visited Mrs. A in hospital about twice a week. He was seen to speak to her rather roughly and she became very quiet and uncommunicative during his visits. Her son once visited while under the influence of alcohol and Mrs. A appeared wary and frightened of him. A neighbour also visited on occasions and revealed to nursing staff that the family was well known in the area for frequent violent disagreements which predated the onset of Mrs. A’s illness. At a case conference three weeks after admission, Mrs. A’s family attended along with the consultant psychiatrist, the social worker, the occupational therapist and nursing staff. The family said they were keen to look after Mrs. A at home and declined the offer of home carers to help with her personal hygiene etc but were keen to have day care at a local day centre twice a week and to access respite care in a residential home every two months or so. Mr A felt that he could continue working in a nearby factory and that Mrs. A could be left alone for periods in the daytime. Their daughter attended a local college and their son was unemployed but was not usually or reliably around. It was thought by the professionals present that discharging Mrs. A with this level of care would not be safe. The family were adamant that if they wished to take Mrs. A home, then they had every right to do so and that they could not be prevented from discharging her. Despite her lack of capacity to make a decision about her future care, Mrs A was able to express an opinion and it was ascertained that she wished to go home. However, she thought she still lived in her childhood home and she did not appreciate the limitations on her ability to care for herself. Key questions underpinning the referral to the Clinical Ethics Committee Our team has approached the CEC to discuss the case, with the following questions in mind: 1. Is it ethical to discharge Mrs. A to the care of her family, in the knowledge that, in the opinion of the professionals concerned, she will get less than adequate care? 2. What is “adequate care”? Should members of the care team judge the domestic situation based on their own standards or the standards normal for this family? 3. Are we depriving Mrs. A of her liberty illegally? 4. What solution is in Mrs. A’s “best interests”?