Ethical Case Discussion with the 4 year medical students
of introductory clinical medicine course, 2000

Case 2)
86 years old lady.
After losing her husband 4 years ago, she was living alone in a small
mountain village.

In the health care workers' meeting of that village, home helper and
community health nurse said this patient says the different thing each
time they visit her. Sometimes she forgot eating for two days
and heating stew pot and scorched. The workers are afraid that she
was suffering from senile dementia and they say it is dangerous to
live alone. They asked her "Please come to the nursing home to live
with others and safely." But she answered "I am all right. I need not
stay in the nursing home."
The clinic's doctor in that village checked this patient, but at that time
her condition was good and she spoke coherently.

She has two sons, but they live in a distant city  (even if they use
an airplane, it takes more than 6 hours). The health care workers
in the village want to talk with this patient's sons, but they did not
come back to the village even in Syougatu (The New Year's Day:
Japanese people usually go back to their parents place on Syougatu
as the western people do in their Christmas Holidays.)

She dreamed that her son will come back to the village. But
she says she doesn't want to go to her son's place because she
does not want to separate from the house and the friend.

If you were the doctor of the clinic of this village.
What do you do to this patient?

Howard Brody
Department of Family Practice and Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing, MI USA.

Topic:  Elderly Patient, Unsafe Home (Japanese case)
Conf:   Patient Autonomy
Date:   Monday, January 24, 2000 12:13 PM

This patient exemplifies one of the saddest dilemmas I have faced in my own practice, which is the problem of a patient with a gradual deterioration of mental capacity, wishing to go on living at home, where the environment is increasingly unsafe for her. The case becomes easier when there is a sudden event such as a stroke; it is usually clear to all parties that the post-stroke patient cannot go back home. But in this case, the deterioration is so gradual that it is very hard to draw a line and to say that this week the home is TOO unsafe while last week it was still just barely tolerable.

Presumably the village team, which is a great resource in caring for this sort of patient, could discuss the case with the sons by telephone or e-mail even if they cannot come personally. But the sons may be of little help if they have not seen their mother for some years.

My own view is that the quality of life of an elderly person is often reduced so much by being removed from her own home, that a decision to risk death or worsening of disease, in order to keep a person in her own home, is often warranted. In the US, today, home health nursing agencies seem often to be motivated by legal concerns rather than by compassion for the patient. If they decide, based on their administrative rules, that a home is unsafe, they often insist upon moving the person out of the home, just to avoid any possible lawsuit later on. So in my own practice I have often had to "fight the system" to try to keep an elderly person in his or her own home when I thought this was best for him or her all around.

Sadly, this problem exists at a certain "middle" stage of dementia. If the patient were more severely demented she could no longer fully appreciate her home environment and so it would matter less where she lived.

Tom Tomlinson
Michigan State University

As Dr. Brody says, these sorts of cases are also very common in the U.S. There are
two sorts of factors which make them complicated. The first is that it is not always
clear whether the person still has enough mental competence to make a decision to
continue living at home, even with the danger. In this case, for example, it is one
thing if she cannot remember that she has left pans on the stove; it is another is she
does remember that she has forgotten pans on the stove. In the first case, she may
not be competent enough to make a decision to continue living with this sort of risk.
In the second case, she may well be competent to make this decision, even though in
other ways she is becoming more demented and forgetful. The second source of
difficulty is with deciding what in fact may be best for this patient. Dr. Brody points out
that removing her from her home against her will may lead to rapid deterioration in
her health. On the other hand, continuing to live at home may result in a much more
gruesome death (for example, burning to death in a fire) than she would suffer if she
were in the nursing home. I don't know of any method for deciding how to balance
these risks to decide which one is the more important to avoid.

If you kindly send your comments on this case, please send it to the
following mail adress.

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Masashi Shirahama M.D.
Director, Mitsuse National health Insurance Clinic
Clinical Professor, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan