Chapter 21: Ethics & Informed Decision Making

Case Vignette Part 1: Introduction and Ethical Tensions

You are in clinic seeing a longstanding patient, an 87-year-old woman with diabetes, congestive heart failure, hypertension, and mild cognitive impairment. She ambulates using a cane. The patient’s adult daughter accompanies her on this visit. The daughter lives several towns away, and prior to today had not visited for several months. The daughter reports being shocked at the deteriorating condition of her mother’s home. She describes a cluttered house, with trip hazards everywhere and stinking piles of garbage in the kitchen. The patient herself says she has some recent difficulty with her vision, but other than that believes she is doing fine. On examination, her blood pressure is 180/82 mm Hg, and her score on the Montreal Cognitive Assessment (MoCA) is 23/30. Laboratory tests show a HbA1c (glycosylated hemoglobin) of 12.5. A visit by a home nurse confirms the daughter’s concerns about the living situation, also noting that the patient’s medications have been removed from their bottles and placed together in a jar on the dresser. When you meet the patient next, you explain your concerns about her living situation and ability to care for herself. She responds that she’s doing “just fine,” and, “I won’t move into a nursing home!”