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What Is The Course Of Action For Meniscus Tear Causing Severe Pain In An Obese Elderly Woman With No Physical Activity?
Question: My 80 y/o mother has had Alzheimer's since Feb. 2011, although only diagnosed via MRI in Dec. 2014. She is in a very nice memory-care unit, still bowel and bladder continant, is extremely forgetful, and believes that every new place she goes (restaurant, stores, etc.) are places she "just went to yesterday" or are places she's always frequented. Her hygiene has suffered; the staff supervises but nevertheless allows her to shower in her own. She has a torn miniscus that not only causes pain, but also makes her exercise walks very painful, with considerable pain during non-activity. The orthopedist is very concerned that a hip-breaking fall is inevitable; she refuses to use a brace, cane, or walker. He says a simple arthroscopic treatment would fix the year -- but my brother is first POA and refused to have it done because she doesn't want to. I believe that she utterly lacks volition and agency and that we should schedule the procedure, take her thete, have her become livid and belligerent BUT relieve her pain and reduce risk of a consequential fall. She is also obese, largely because her knee hurts and she doesn't walk much anymore. What is the best course of avtion? The staff all see the need for treatment, but my brother refused to consider it because of her stated rejection of ANY procedure or medicine (although two months ago I secretly convinced the nursing director and the visiting AT NO to give her two ibuprofen every morning, a change both she and my brother are unaware of. I guess the question is: How much should a seven-year Alzheimer's patient's wishes re: medical treatment s at those decisions?
Brief Answer:
What is needed is a Guardianship
Detailed Answer:
The wishes of all patients should be taken into consideration so long as they are known to be competent and capacitated meaning that they understand what is happening and the consequences of treatment or withholding of the same. In your mother's case of dementia it is often difficult to be crystal clear in understanding that her saying NO to a procedure such as you describe is driven by pure lack of understanding of her situation versus an actual NO because she truly does not wish to have the procedure done under any circumstance. Even trained and licensed psychologists and neuropsychologists have a hard time wrestling with when a demented person says what they want or not as being true to their sentiments or voiced because of misunderstanding or lack of comprehension. What seems logical and straight forward to one person for the care or interest of another is not always what that person believes is in their own best interest. That is why the ethical principle that always guides is that of "what would the PERSON have wanted for themselves if they were not in such a cognitively impaired state?" Your brother has a different perspective than you do on this question...or so it would seem.
That is why GUARDIANSHIPS exist which supersede the actions and authority of POA's. I believe your brother has a POWER OF ATTORNEY perhaps designated to him by your mother at some time in the past through an estate plan and the wishes of your brother as POA (as far as the nursing home or hospital/doctor, etc.) are concerned are in fact, legally binding to a certain extent. That is, until they are challenged in court.
THAT is where the process of a GUARDIANSHIP begins. If you as a member of the family feel that your brother's decision in respecting what your mother SAYS is contrary to what your mother would do under circumstances of being fully competent, capacitated, and NOT demented (i.e. your mother would've done this procedure years ago using your rationale and logic) then, you can challenge the authority of the POA by filing a probate case and applying for a Guardianship. This is a lengthy and costly process in most cases and it will most certainly place you at odds with members of the family.
However, it is the way to enforce medical decisions that YOU feel are in the best interest of your mother. In addition, it is the legal tool necessary so that neither you, the nursing or anyone else are exposed to violations of law or recognized authority. As it stands, things you have done (as benign as they may appear) in convincing the nursing home to give her analgesics, etc. could be construed by your brother as violating his authority and that is a potentially complicated situation.
Nobody should suffer unnecessarily in medical circumstances beyond their control.....however, the legal process by which that is accomplished can be winding and fraught with complexities. The nursing home and the orthopod will likely respect the wishes of your brother going forward since legally he is highest in authority at this time and has already set precedents of control and decision making which are currently being followed. Courts will look at this when deciding on who may or may not be eligible for a guardianship, however, what you should ask yourself at all times when contemplating medical (or other decisions) is, "Is this something mom would've clearly and unequivocally done of her own accord using the same rationale and information as I have had she been fully competent and capacitated?"
Good luck.
What is needed is a Guardianship
Detailed Answer:
The wishes of all patients should be taken into consideration so long as they are known to be competent and capacitated meaning that they understand what is happening and the consequences of treatment or withholding of the same. In your mother's case of dementia it is often difficult to be crystal clear in understanding that her saying NO to a procedure such as you describe is driven by pure lack of understanding of her situation versus an actual NO because she truly does not wish to have the procedure done under any circumstance. Even trained and licensed psychologists and neuropsychologists have a hard time wrestling with when a demented person says what they want or not as being true to their sentiments or voiced because of misunderstanding or lack of comprehension. What seems logical and straight forward to one person for the care or interest of another is not always what that person believes is in their own best interest. That is why the ethical principle that always guides is that of "what would the PERSON have wanted for themselves if they were not in such a cognitively impaired state?" Your brother has a different perspective than you do on this question...or so it would seem.
That is why GUARDIANSHIPS exist which supersede the actions and authority of POA's. I believe your brother has a POWER OF ATTORNEY perhaps designated to him by your mother at some time in the past through an estate plan and the wishes of your brother as POA (as far as the nursing home or hospital/doctor, etc.) are concerned are in fact, legally binding to a certain extent. That is, until they are challenged in court.
THAT is where the process of a GUARDIANSHIP begins. If you as a member of the family feel that your brother's decision in respecting what your mother SAYS is contrary to what your mother would do under circumstances of being fully competent, capacitated, and NOT demented (i.e. your mother would've done this procedure years ago using your rationale and logic) then, you can challenge the authority of the POA by filing a probate case and applying for a Guardianship. This is a lengthy and costly process in most cases and it will most certainly place you at odds with members of the family.
However, it is the way to enforce medical decisions that YOU feel are in the best interest of your mother. In addition, it is the legal tool necessary so that neither you, the nursing or anyone else are exposed to violations of law or recognized authority. As it stands, things you have done (as benign as they may appear) in convincing the nursing home to give her analgesics, etc. could be construed by your brother as violating his authority and that is a potentially complicated situation.
Nobody should suffer unnecessarily in medical circumstances beyond their control.....however, the legal process by which that is accomplished can be winding and fraught with complexities. The nursing home and the orthopod will likely respect the wishes of your brother going forward since legally he is highest in authority at this time and has already set precedents of control and decision making which are currently being followed. Courts will look at this when deciding on who may or may not be eligible for a guardianship, however, what you should ask yourself at all times when contemplating medical (or other decisions) is, "Is this something mom would've clearly and unequivocally done of her own accord using the same rationale and information as I have had she been fully competent and capacitated?"
Good luck.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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