One thing that frustrates many of my elderly patients is the idea that a time will come when they are deemed incompetent and unable to make their own medical decisions.
This week I had one such patient but her situation had one major difference - she was perfectly competent. In nursing school, you learn the definitions of orientation in your patients - a perfectly lucid patient should know at least his or her name, date and time. In my facility, we ask if the patients understand their situation as well.
She was 93 and spent most of her life taking whatever various vitamins she took and for most of her life, she was very healthy and what she was doing worked out for her. But now, at age 93, she is sitting in a hospital bed and has been for several days. After refusing most of the recommended and prescribed medical treatment, the doctor covering her ordered a psychiatric consult.
In the three days I was her nurse, I spoke to her son several times. Our first conversation was where he told me she had been labeled incompetent and the decisions were now up to him, as he was her power of attorney. I had not gotten this piece of news in report from the night nurse but the patient was perfectly willing to tell me all about it. Repeatedly. Loudly.
Curious, I took a look at this note. What led the psychiatrist to this conclusion was firstly, that she was refusing all of her medications and treatment. Secondly, when he or she asked the patient about what the doctor said, all she would say was what she wanted and how everything she had been doing had been working her whole life and that nothing needed to change now.
This woman wanted to go to rehab. Everyone in her family even remotely involved wanted her to go to rehab. Unfortunately, her blood pressure, even done manually, often registered in the 200's. All of the physical and occupational therapists on my unit take blood pressures before working with patients and they always call me when patients have blood pressures like that. Until the blood pressure is controlled, they won't work with them because they don't want to take the risk of causing a stroke. A rehab doctor deciding whether or not to admit her to a facility will have similar guidelines.
Over and over, we all heard about how her blood pressure has always been this high and that there is nothing that can be done about it. Furthermore, she was focused on getting a psychiatric re-evaluation to prove she was competent. But for her, the psychiatric consult was only relevant to her pride. The ultimate decision was rehab. The patient wanted rehab. The doctors recommended rehab. Her family wanted her to go to rehab. The exact decision she wanted would be made no matter who was officially making it. Honestly, it had already been made: the only thing holding her back was her refusal of medical treatment.
Some of her friends came in and wanted to provide the hospital with information about labile blood pressure that was supposedly supported by the American Heart Association (which may have been true and I would have been more than happy to read such studies) and to sue the hospital for deeming her incompetent.
I haven't had a very long career. I haven't seen everything. I like to think I've seen a lot of things but this is the first time I've seen a patient who is both competent and incompetent.
Wednesday, December 31, 2014
Monday, December 29, 2014
Wife of patient: You're Jewish and 27, why aren't you married? You should really try Saw You at Sinai. I know people who have gotten married, it's all rebbetzins who set you up. My friend Sharon has a son. Is 38 too old? He has a kid, how do you feel about that? I bet if he fell in love with you, he'd keep kosher!
...Oy vey.
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