Ethics Corner: Cases from the Hebrew Rehabilitation Center for Aged—Friends

Abstract

Miriam S. is an 85-year-old woman who was admitted to the Hebrew Rehabilitation Center for Aged (HRCA) from her apartment in the community 5 years ago. She was admitted after a visiting social worker observed that Ms. S. had difficulty with personal hygiene and with making her way back to her apartment after performing errands. Ms. S. was born and raised in Boston, completed high school, and worked in a department store until retiring at age 65. She never married. She had one surviving sibling with severe dementia who was a resident of another nursing home. Upon admission to the HRCA, Ms. S. was diagnosed with mild dementia and hypertension. Her niece, who had previously agreed to assume the role of durable power of attorney, refused to be the health care proxy for her aunt, though Ms. S. would have willingly appointed her. Over the next few months, Ms. S.’s social worker at HRCA inquired of the niece on several occasions about becoming her aunt’s health care proxy, and on each occasion the niece declined. One year into her stay at the HRCA, Ms. S. fell and fractured a hip. The medical treatment team found that Ms. S. retained the capacity to make medical decisions, and her hip replacement surgery and recuperation were uneventful. Over the next 2 years, Ms. S.’s treatment team observed slow progression of Ms. S.’s dementia. After Ms. S.’s niece again declined to become the health care proxy, the treatment team referred Ms. S. to the Ethics Committee’s Informal Surrogate for the Unbefriended program. A member of the Ethics Committee was designated as the informal surrogate. She began to meet with Ms. S. on a regular basis and recorded in Ms. S.’s chart details of conversations about advance directives. Five years after her original hip surgery, Ms. S. required surgical revision of the hip. Ms. S’s informal surrogate was included in discussions about the surgery. The orthopedist recognized that Ms. S. had impaired decision-making capacity but felt that she retained the ability to make a valid decision about the procedure. Ms. S. agreed to the surgery and her surrogate believed that her consent was consistent with previously expressed goals for her health care. The surgery proceeded without incident.