In the Life: A Case of Autonomy, Exploitation, and Undue Influence in Geriatric Home Care

Abstract

How Come?You ain't my brother nowI don't trust wayYou stamp your feet on meI don't shine upTo this devil-goosin' stuffYou been layin' on in my behalfOh you ain't my lovin' buddy nowSometime I think mannerYou come in my houseAnd dirty-arm me aroundIs something I don't particularly cherishKenneth PatchenHurrah for Anything ( 1957)UP IN THE OLD HOTELMr. G was an 88-year-old man who lived in a single-room occu- pancy (SRO) residential hotel in New York City (NYC). This hotel was once a traditional SRO for short- or long-term stayers but is now run by a privately funded social service agency as a low-cost residence for independently living adults older than 55 years. Many are formerly homeless and were referred by NYC Department of Homeless Services, whereas others were marginally housed and referred by community agencies. Mr. G was a self-referral and had lived quietly in same room for 24 years.There are about 275 residents in building, in a colorful cross- section of NYC life, ranging from self-described Bowery bums blue-collar workers and secretaries professional dancers, musicians, and artists. Each room has its own bathroom but no kitchen. The hotel provides weekly housekeeping, two low-cost meals a day in its cafeteria, and social work services by a staff of six. Monthly contact with a case manager is required, as is a home visit every 6 months, but finances are not routinely monitored. The hotel also sponsors activi- ties such as exercise and crafts classes, entertainment and outings for residents, and features a library and computer room, TV room, and drop-in center for homeless older adults.The Department of Community Medicine, founded in 1969 at former St. Vincent's Hospital and now under Lutheran Family Health Centers, has run a small part-time clinic at this hotel for more than 30 years, caring for street homeless and hotel's residents alike on a walk-in or ongoing basis. The team has known many residents for years, beginning in shelter clinics and hospital-based SRO clinic, and once patients are housed, continuing care at hotel. Some become homebound, requiring home visits, a visiting nurse, and even hospice enable them remain in their precious and hard-won rooms. Some attend weekly for medication management and checkups. Our team is made up of a nurse, a social worker, an outreach worker, and a physician, who all work at other program sites as well, and we see about 25 patients a week. The physician is a graduate of Mt. Sinai's medical school and St. Vincent's internal medicine primary care residency; clinic currently hosts Mt. Sinai medical students.The PatientMr. G was first seen in 2002 for a flu shot and a pneumonia shot- denied depression, declined medical care, and did not respond recall slips and outreach visits. He next came in 2003 for a flu shot given by another physician. In early 2007, was brought in by social work supervisor and saw nurse. He had been scheduled for cataract repair at New York Eye and Ear Infirmary, but did not go, feeling nervous. He did not return follow up with doctor. In spring of 2007, his case manager came ask if we could bathe a resident-we suggested an aide and bring resident in-later this turned out be Mr. G.A new case manager joined staff, made a home visit, and brought Mr. G clinic in May 2007. He said that had fallen recently and gone Cabrini Hospital emergency room (ER). Records showed that was at scene when EMS came hotel for someone else-he was taken in as well because was leaning against a wall and he didn't look good per notes. He left ER against medical advice to follow up with primary care doctor after being told that his chest x-ray showed a lung mass. Now wanted us find results of the x-ray of spot on lungs. …