Annals of Long Term Care

INTRODUCTION
Ethical issues are frequently encountered in caring for elderly patients in both acute and long-term care settings. The authors describe a case concerning an elderly male with a newly diagnosed advanced dementia and progressive neurologic disorder, who did not wish to be evaluated or treated based on his Christian Science religion. The authors explore the ethical dilemmas, describe the various ethical principles involved, and illustrate the complexity of medical decision-making. Ongoing discussions with family and appropriate multidisciplinary consultations are key to the clinical management of such cases.

CASE PRESENTATION
Law enforcement discovered an unidentified male wandering down a rural road after he had apparently abandoned his vehicle after hitting a mailbox. Mr. A was brought to a local emergency department for evaluation, where he was noted not to be able to respond to questions. Evaluation with complete blood count, electrolytes, urinalysis, urine drug abuse survey, and electrocardiogram were within normal limits. A computed tomography scan of the head was negative for acute pathology. He was then transferred to our facility for admission to the geriatric psychiatric unit for his safety and further evaluation.

Admission examination showed an elderly male who was malodorous and poorly groomed, with visible dirt on his skin and clothing. There were no signs of physiological or emotional distress, and he lay down quietly on his hospital bed with minimal interaction. Multiple attempts to interview him were unsuccessful, as he responded to all questions with the word “no.” A closer inspection of his belongings revealed multiple documents referencing Christian Science, including a note encouraging him to continue seeing a Christian Science practitioner rather than a medical doctor, numerous business cards, expired driver’s licenses, multiple card keys and receipts from local motels, a large amount of cash, bank statements with large balances listed, and good quality clothing stained with dirt and urine.

During his hospitalization, Mr. A continued to respond only “no” to questions. He indicated at times, using body language or broken speech, that he meant to convey an answer other than “no”; for example, when asked how many children he had, he held up two fingers while saying no. Despite this language deficit, he was notably able to decline treatment by writing to his treating psychiatrists, “No medications. Christian Scientist.” He did not demonstrate any affective or psychotic symptoms. Gross physical inspection revealed prominent bruxism; he refused a physical examination other than auscultation of his heart and lungs, which were normal.

Mr. A’s former spouse contacted the hospital and provided documentation that she, along with his sister, were his appointed power of attorney (POA) for healthcare decisions. She described a history of progressive decline in his ability to communicate over the last few years and repeated episodes of acute confusion. Several months earlier he left his home and traveled a few thousand miles to another state, where he spent time moving from one motel to another. Approximately three months earlier, he had been hospitalized at another facility after law enforcement had found him wandering in a confused state. She stated that he underwent a medical and neurological work-up that was “all normal.” That facility had recommended placement in a nursing home or assisted living facility, and discharged him to care of his sister. While visiting various facilities with his sister, he “escaped,” as he had continued access to his vehicle and resumed his travels between motels. His family had not had direct contact with him, although the desk workers from the motels would call his sister to give her updates on his condition.

Mr.