Annals of Long Term Care

The number of older adults residing in long-term care (LTC) facilities is expected to increase considerably as the baby-boom generation reaches retirement age. Studies indicate that many psychiatric disorders are more prevalent in older LTC residents than in elders who are community-dwelling.¹ With a potential explosion in the need for LTC services and more dependent adults requiring mental health services, healthcare providers may increasingly encounter challenging cases, such as of the elder who exhibits aggressive and abusive behaviors, leading providers to wonder how to handle such elders and what their ethical duties to such individuals are.

We present the challenging case of a 72-year-old man classified as having a personality disorder not otherwise specified (PDNOS), along with almost every feature of antisocial personality disorder. The patient demonstrated particularly aggressive drug-seeking behavior and was eventually admitted to a skilled nursing facility (SNF). At the facility, he attempted to gain access to opiates by continuing his practice of feigning illness and pain. Various treatment strategies were ineffective, and staff at the facility struggled with caring for this malingerer.

Our case scenario highlights the ethical dilemmas that arise in the professional–patient relationship when the patient is a malingerer. A literature search did not provide guidance, as we could not locate any cases of drug addiction and personality disorder among frail older adults, particularly cases of aggressive drug-seeking behavior in this population. With a paucity of information on such cases, it is unclear at what point the rights of a patient and the obligations of the practitioner break down when the patient acts in bad faith. Ethical discussions in medicine usually assume that healthcare providers have an obligation to help patients, but patients are also assumed to be both moral and in need. Questioning healthcare provider obligations, even when a patient’s moral integrity is lacking, can lead to healthcare providers being viewed as abusers of patients and in need of principles and rules to guide their moral behavior and preclude abuses. We examine the medical ethics concepts of patient autonomy, social and professional beneficence, nonmaleficence, and social reciprocity, and discuss how these concepts need to be adapted when the patient does not act in good faith. We also review the challenges of caring for psychiatric patients in dependent care settings, which are subject to regulations established by the Omnibus Budget Reconciliation Act of 1987 (OBRA).

Case Scenario

A 72-year-old man was admitted to the hospital after being treated in the emergency department for opioid and benzodiazepine dependence. A urine drug screen was positive for amphetamine, benzodiazepines, and methadone. The patient was well known to the admitting service for a protracted history of opioid, benzodiazepine, and amphetamine abuse, and opioid-induced depressive mood disorder. He had multiple hospital admissions over a 7-year period, with 22 at one facility and 23 at another, as well as uncounted emergency department visits and outpatient clinic encounters. These admissions were for acute intoxication or suspected overdose of multiple substances, and for suicidal gestures, suicidal threats, and suicidal ideation.

A retrospective review of his medical records revealed patterns that would not be evident by viewing each admission as a single event. We found that the patient’s “overdoses” were largely self-reported and although urine drug screens were positive for multiple substances, levels were not obtained or not documented and he required very little drug treatment for “detoxification.” The patient’s suicidal behavior, used to obtain hospital admission, vaporized shortly after his admissions, when his psychiatrists repeatedly determined that he had no suicidal risk. While at the hospital, the patient demanded opioid medication, and he left the hospital against medical advice on at least eight occasions, usually when he did not get the medication that he demanded. The patient consistently refused to cooperate with his treatment plan or to take the nonopiate pain medications prescribed for him, stating “Morphine is the only thing that works.” On all occasions, he reported his pain as a 10 on a 0–10 pain scale, but without naming a specific location on his body. His functional assessments showed no impairments due to physical pain.

Following his latest admission, once the detoxification protocol was completed and a clinical assessment showed no active suicidal or homicidal ideation, he was transferred to an SNF for social reasons, with specific transfer instructions for no opiates. Immediately upon arrival at the SNF, he began demanding opiates of every passing physician, nurse, and social worker. In pursuit of opiates, he would ambulate rapidly and without difficulty to persistently follow nurses into other patients’ rooms. He repeatedly refused his prescribed pain medications, demanding opiates instead, and on at least one occasion threatened suicide if his demands were not met. When encountering any new covering provider, he would display transiently impaired gait to demonstrate his need for opiates. When he was denied opiates, his gait would return to normal, with a normal, self-selected gait speed.

The patient would demand to be bathed, dressed, groomed, and fed despite being able to perform these tasks himself, as witnessed by his care team. Additionally, he gained >10 lb while in the facility despite not being fed by staff, indicating his ability to nourish himself. He unrelentingly cursed and verbally threatened his therapists and nurses, despite repeated admonitions about inappropriate behavior and the use of security intervention on several occasions. At an interdisciplinary team meeting, he was counseled that he could be discharged from the SNF or arrested if staff pressed legal charges for his threats and assaults. Finally, he conspired with the wife of another patient to abscond against medical advice and was driven to a city several states away, where he presented to another in-patient facility, which had him transported back to his home of record. On his return, he was accepted into a group home, but immediately ransacked the room, vomited copiously on the furnishings, and was brought back to our hospital, where he requested opiates for pain. When opiates were denied, he claimed suicidal ideation. Upon being readmitted to the hospital, his abusive behavior to staff immediately resumed.