Chapter 1. Test1

Introduction

Written by Elaine Cassel, J.D., M.A.

Lord Fairfax Communtiy College

(c) 2013 Worth Publishers (Photo Credit: John Knill / Getty Images)

1.1 Presenting Complaint

Fred is a 72-year-old white male, who was employed part-time at the time of his illness. After presenting with a serious medical problem at the local hospital, a series of mistakes led the social services and legal systems to become involved with his care. As a result of both medical and legal errors, Fred and his wife Angie were removed from their life-long home and placed in a nursing home. Fred was declared incompetent to handle his personal or physical affairs and a guardian was named to handle his medical and financial affairs.

One fall day, Fred left his modest suburban home for his part-time job at the county park authority. He had worked for the county parks authority since he got out of high school 54 years ago. He reduced his hours to part-time at the age of 65. He was in good health, though not as strong as he used to be, so his job was now limited to light work such as emptying trashcans, moving furniture, sweeping, and the like. Shortly after he had eaten lunch, Fred was overcome with abdominal pain. He went to his supervisor and told him he had to go home. But Fred looked so bad that his supervisor did not want him to drive. He drove Fred to the local hospital which was a large and intimidating facility. After several hours of waiting, Fred was examined by an emergency room doctor. The doctor suspected a urinary tract infection but, given Fred’s age, she wanted to take some tests to make sure. Fred was admitted to the hospital.

Fred was anxious about getting in touch with his wife Angie, but had no way to reach her. He finally got a nurse to call Angie. Angie was frightened but unable to come to the hospital as she had quit driving some years ago. The doctors immediately started Fred on antibiotics administered with an IV to treat a possible infection. They also gave him some painkillers, as Fred was complaining of severe stomach pains. Alone in his room, without Angie by his side, Fred became agitated. The nurses reported it to the attending physician, who recommended valium, a benzodiazepine, to calm him down. Fred had a fitful night and in the morning, the tests the doctor ordered disclosed the need for a minor surgical procedure to open up his urethra. He had an enlarged prostate gland, not uncommon for men his age, and most likely this was a factor in the urinary tract infection, which had been confirmed.

Fred was sedated, and then put under general anesthesia for the procedure. By this time, Angie had contacted a niece, Bernice, who came to the hospital to be with Fred. When Fred awoke from the general anesthesia, he appeared confused and agitated. The nurses gave him more painkillers, more antibiotics, and more valium, but this only upset him more. He wanted to know where he was, where Angie was, and why all these strangers were doing all these procedures on him. At one point, he did not even recognize Bernice, whom he had known since she was a baby.

The second full day of his admission, a hospital social worker came to check on Fred. This was a common practice in this large hospital, which treated many Medicare patients. Her intentions were good—to see what kind of help Fred had at home before discharging him from the hospital. Her job was also to make sure that Fred did not need to spend time in a rehabilitation facility or a nursing home before going home. When the hospital social worker saw Fred’s confused and agitated state and talked to the nurses, she determined that he was suffering from some sort of neurocognitive disorder, but most likely not Alzheimer’s given his work history.

The social worker questioned Bernice, who reported that Angie and Fred lived alone, and that Fred cared for Angie and kept the house going. Not knowing how that could be possible, given that Fred appeared to have a neurocognitive disorder, the social worker became alarmed. Unbeknownst to Bernice and, of course, to Angie or Fred (who appeared angry and confused when he was awake), the social worker contacted the psychiatrist on call to do a mental status evaluation. If the psychiatrist agreed with her, and concluded that Fred was suffering from major neurocognitive disorder, she would then start the legal process to have Fred declared a ward of the court. The court would appoint a guardian for him, and take over all of his assets and, most likely, put him in a nursing home.

The psychiatrist did indeed come into the room and after having Bernice leave, did a five-minute mental status exam on Fred, asking him his name, his age, the date, who was the president, what season it was, who won the World Series last year, and the like. The only answer Fred got right was his name. He stated his age as 68 and he did not know the date or the answers to any of the other questions. The psychiatrist never once looked at Fred’s chart to see how many medications he was taking or that he had been running a low-grade fever since the surgery, despite being given massive doses of antibiotics. Had he done so, he might have recalled his medical training in which he learned the difference between neurocognitive disorders, which represent a permanent state of cognitive impairment, and delirium, a temporary state of confusion that is often the result of taking several medications, the effects of surgery, and the disorienting atmosphere of a large hospital. Instead of doing a full investigation, the psychiatrist wrote these words on Fred’s chart—“major neurocognitive disorder, probably of the Alzheimer’s type, irreversible.”

The social worker took the psychiatrist’s report and called the attorney the hospital used to petition the court to appoint a guardian for a person unable to make decisions for him or herself. Bernice assured her that she would see that Fred and Angie were taken care of, but the social worker said Bernice would have to discuss that with the judge.

On the Friday of the same week that Fred was admitted to the hospital, the attorney went to court, having left a copy of the court petition on Fred’s bed (what the courts called “serving” Fred with notice). He presented the psychiatrist’s report to the court and asked the court to declare Fred incompetent and to allow him, the attorney, to take over his assets and put him in a nursing home. The attorney told the judge that the hospital psychiatrist had determined that Fred had an irreversible major neurocognitive disorder and was unable to care for himself. He reported that the county department of aging would visit Angie and see if she needed to go into a nursing home as well. The judge only read the petition in front of him, which stated that Fred was suffering from a major neurocognitive disorder and ordered that he be declared incompetent under the law and have a guardian appointed to take care of his affairs. When Bernice tried to speak and say she wanted to be the guardian, the judge told her she would have to discuss this with the attorney he had just appointed guardian. Now that attorney was the only one with the power to make decisions about Fred’s life and welfare.

By Sunday, Fred was discharged to an expensive nursing home, and Angie was being talked into going with him by a county social worker. The funds to get them into the nursing home came from their bank account, which the court-appointed guardian now had access to. The move to a nursing home was upsetting; as soon as Fred arrived by ambulance, he had to be taken back to the hospital where it was found that he was still suffering from the urinary tract infection. This time, all decisions about his care were made by the guardian, a stranger who was not required to contact anyone.

Fred remained in the hospital for three more days, where he continued to receive medications for his infection and pain and, this time, a stronger anti-psychotic medication. After all, he now had a psychiatric diagnosis, not just a medical one. When Fred returned to the nursing home, Angie was there. Although he was happy to see Angie, Fred was even more confused because he knew he was not at home. Angie was crying when he was brought in. Fred broke down and cried with her. Bernice was heart-broken at the sight of them, two lovely elderly people who had not spent a night out of their home for years, now in a nursing home, at their own expense. The nursing home agreed that Angie could stay with Fred until he was released, but Bernice already knew that they would probably be here for a while. Fred was not so frail, but Bernice knew he wasn’t going home anytime soon. And Angie could not stay by herself in the house.

Bernice was so upset that she called a local attorney who dealt with mental health issues. The attorney contacted a neurologist and psychiatrist to help her review his medical records and history. They determined that Fred had not had a neurocognitive disorder at the time of the examination. He was suffering from delirium. But Fred had been so compromised by the drugs, the hospitalization, and the removal from his home to a strange place, that he was now suffering from a form of neurocognitive disorder which was likely to get worse. If left untreated in the elderly, delirium can lead to a type of neurocognitive disorder. By now, Fred was not able to manage his finances or make good decisions about his medical care. He was in no shape to go home and try to keep house and cook for Angie. Bernice knew that the only solution was for Fred and Angie to remain in the nursing home for what would probably be the rest of their lives. The attorney was able to get Bernice named as Fred and Angie’s guardian. Eventually, the attorney won a lawsuit against the psychiatrist and the hospital, but it was too late for Fred and Angie. They would never return home. After several years, they died in the nursing home. Fred never regained the mental or physical health he had on the day he last worked, that nice fall day in September.

1.2 Social/Family History

Fred was a high-school educated blue-collar worker. He was married to Angie, his high-school sweetheart, for 52 years, at the time he presented to the hospital with his urinary tract infection. They lived in a modest two-bedroom, one-bath home that they had purchased 40 years ago. They didn’t have any children or close friends. Angie, who was also 72, never worked outside of the home. Her health was not as good as Fred’s. She was thin and frail. Fred did most of the cooking and cleaning and friends and neighbors looked in on them occasionally to make sure they were getting along. Fred and Angie had been very frugal. They owned their home, had only one vehicle—a pick-up truck that Fred drove to work—and they had amassed a significant amount of savings which they kept in certificates of deposit in a local bank.

They had a niece, Bernice, a daughter of Angie’s deceased sister, who was their closest living relative. She was the only reliable person Fred and Angie could call if they needed help. Fortunately, Bernice stepped in and took over as their guardian when it was clear that Fred and Angie could never live independently again.

1.3 Multiple-Choice Questions