- The Individual Rights of the Difficult Patient
Mr. A is a fifty-five-year-old man who became quadriplegic eight years ago after suffering a spinal cord injury during a drunk driving accident. Once recovered, he investigated visiting nurse services and home care attendants but decided that entering a nursing home would be his best and easiest option. He has little motor function below his neck and requires constant care. Prior to the accident, his only medical problem was high blood pressure, but in the years since he has suffered many debilitating complications, including chronic prostatitis, multiple pressure sores, and fractures due to osteoporosis. He has also had to undergo a colostomy and an ileostomy.
In the time since the accident, his behavior has been a continual problem. He has already been thrown out of one nursing home, and his conduct is getting worse. He regularly accuses the staff at his new home of committing various illegal and unethical acts. He frequently insults them, hurling racial slurs at them and using sexually explicit terms. He repeatedly threatens to harm other patients and their families as well, which leads staff to place him in a private room. On eight occasions he has tried to assault people with his motorized wheelchair, once leaving the facility and attempting to hit people on a busy street until police intervened. Mr. A often refuses care and meals if they are not offered according to his schedule by staff of his choosing, then complains he's being denied care or neglected. He also rejects medication and treatment at the cost of his health—a practice that may endanger his life.
Mr. A disrupts the entire nursing home. His complaints of improper care were so incessant that, with his consent, the facility installed a surveillance camera in his room, yet he still claims staff are not fulfilling his needs and that treatment does not meet his personal standard of care. He has filed eighty formal complaints and writes letters disparaging the nursing home to various individuals and organizations, asking recipients to copy and distribute the letters. He encourages other patients to file complaints as well, offering them the services of his lawyer. A psychiatrist brought in by the staff diagnosed him with narcissistic personality disorder.
An interdisciplinary treatment team has formulated a care plan designed to limit the disruption he causes. When he refuses a meal, he will not be offered food until the next mealtime; a similar plan will be implemented when he refuses medications, treatment, or hygienic care. Aggressive behavior toward other patients will not be tolerated. Though Mr. A says he will abide by these rules, he continues to be disrespectful and aggressive, often becoming enraged at staff if they try to enforce them. The staff feels his behavior still interferes with their care of other residents and their ability to perform their duties.
How can staff best attend to Mr. A's needs in spite of his behavior while also protecting their own rights and those of other patients?
This case demonstrates the conflict that can occur between the rights of an individual and the rights of the community. Mr. A's care providers have an obligation to care for him in spite of his behavior, but they also have an obligation to protect other patients and staff from his actions. They must choose between two general treatment approaches. One option is to continue attempting to treat Mr. A in his current setting along the lines already established. The other is to limit the services he receives, or possibly even terminate his care at the facility. Neither option is very attractive.
Mr. A clearly desires medical care, and an argument can be made to continue caring for him. Like other members of society, he has certain rights to treatment. An individual's rights are often given primary status in contemporary society, and individual autonomy is a correspondingly prominent value in medical ethics. Many feel that the only way to pay proper respect to autonomy is to let patients decide themselves what is good for them...