- Resuscitating a Bad Patient
RD, a seventy-year old man, fell in his home several weeks ago and did not receive assistance for four days, causing pressure sores to develop on his body. He also has multiple chronic illnesses, including diabetes, hypertension, obstructive pulmonary disease, and dementia. After judging him too weak to care for himself, RD's doctors tried placing him in a skilled nursing facility; but his sores haven't healed properly, so he's now been admitted to an academic medical center.
After his admission, RD's medical condition quickly stabilizes. His doctors request that his continuous oxygen saturation monitoring be discontinued, but nursing staff disagree. The monitor often shows that RD has low oxygen saturations, sometimes from taking off his oxygen mask. Low oxygen saturation triggers an alarm that prompts nursing staff to evaluate the patient. Since he doesn't have a "do not resuscitate" order and his durable power of attorney for healthcare can't be reached, nursing staff must try to resuscitate him if he arrests. In their view, continued oxygen monitoring helps them to prevent a cardiac arrest.
Considering his multiple medical problems and overall prognosis, both nursing staff and medical staff agree that DNR status would be appropriate for RD—they feel that, in his case, aggressive care would be futile care. RD does not agree—he wants aggressive care. He also worries hospital staff in other ways. Most of his behavior is consistent with dementia, but he also attempts to manipulate the psychologist involved with the case, deliberately refusing to cooperate and intermittently responding in ways that imply he has more insight into his situation than he lets on. Finally, he's a convicted sex offender. In the past, he underwent intensive psychotherapy to treat his mental disorders, but during this hospitalization he regresses, frequently making sexually inappropriate comments to nursing staff.
Given the challenges of RD's personality and prognosis, how should his health care team approach his continued care?
Delivering patient-centered care means that providers should consult patients (or their proxies) to determine what they want in specific circumstances. The unstated corollary to this is that the providers will then honor those preferences. But what happens when—in cases such as this one—what the patient wants is either medically untenable or socially inappropriate?
The clinical reality is that in a patient with RD's medical status, resuscitative efforts are not likely to succeed and will expend many resources. That indicates that RD's decision to pursue aggressive care is a bad one. Of course, the right to make one's own decision is also the right to make a bad decision, but health care providers must ensure that all decisions are informed ones. Ideally, providers should take this opportunity to talk with RD about the likely outcome of such interventions, possible alternative care plans, and how his values and goals fit in with the proposed treatment. This is difficult in RD's case, as his dementia may limit his ability to engage meaningfully in such a conversation. His power of attorney's absence further complicates the situation. However, the fact that RD deliberately manipulated his interactions with the psychologist demonstrates that he retains some ability to think and reason. His health care providers need to assess the extent of this ability.
RD's inappropriate behavior with the staff may be a reaction to his loss of control. He has only recently moved from living independently to assisted care. He may also be manipulating this situation to his advantage: the more difficult he is with staff, the less likely they will be to find long term placement for him. He may reason that he will then be sent back to his own home—a medically and socially unrealistic outcome.
In the meantime, the nursing staff has the burden of dealing with RD's inappropriate behavior. This raises the issue of professional obligations. The hospital's obligations to staff require that it make a better working environment for the nurses by intervening. One way to do this is for the medical staff to negotiate a behavior contract with RD...