I experienced a very disturbing incident following a recent home care visit. I went in to see a client for a visit and found him very short of breath with a low O2 sat and abnormal lung sounds. This client was not wearing his O2, so I helped him put it on and told him due to his respiratory status he needed to go to the hospital. I asked him if he wanted me to call 911 and he refused but wanted me to call his daughter, which I did. She lives a few houses away and was there within a few minutes. I explained to her that her dad needed to go to the ED. She stated he gets “like this” when he raises the heat too high. She lowered his furnace and opened the door. I asked whether she needed help getting her father in the car and she refused stating she could get him in herself. I left uncertain whether she took his medical condition seriously. The following day I received a call from our HHA who informed me that this client was in the hospital and that the daughter was upset with me because I did not call 911. I called the daughter and she was very upset and apparently felt that I should have called 911 even though her father refused. She stated that he has dementia and I should not have listened to his refusal. We have no record on file as to this patient having dementia and although he is forgetful, he is alert. What is my responsibility if a patient refuses and should I have handled this situation differently?
Nancy Brent replies:
This home situation sounds quite difficult for you to provide the care needed for this patient. First of all, the patient supposedly has dementia, but this is a condition you knew nothing about. Although many family members may believe a family member has cognitive impairment, until a physician or psychiatrist makes that diagnosis and documents it, there is a presumption of competency to refuse treatment. This is one issue that needs to be clarified with the patient’s physician, the agency and the family member.
An individual has the right to refuse treatment, including life-saving treatment, if he or she is competent to do so. Since competency is presumed, there is little else you can do but carefully and completely document the patient’s decision. In addition, a call to the agency and the patient’s physician, also documented, would be essential to alert the primary healthcare provider of the incident, his need to evaluate the patient for cognitive impairment and the impact of the impairment, if any — for example, he can refuse treatment or no he cannot refuse treatment, he can or cannot live alone, etc.
Also, its important to arrange a meeting with the daughter so she is aware of the physician’s diagnosis, her responsibilities (for example, is she the father’s healthcare agent?) and your responsibilities, including the treatment you will provide in the situation and her father’s rights in the situation. It sounds as though she is not clear about these and other issues, which will need to be clarified. A plan of care needs to be established a plan of care that provides the patient with what he needs and helps the daughter understand better how to care for her father. For example, the daughter greeted you with an unconcerned response: He always gets this way when he turns the heat up. Yet, she took him to the ED by herself, which one can only guess is to save an ambulance fee, but may not be the wisest choice for the patient’s safety if he needs his oxygen during the transport. It appears she is the key, along with your guidance, in helping her father get the best care possible in this situation.