Box 13.2 Case study

Mrs Antony is a frail woman of 84 years of age. She is brought into the emergency department by ambulance following a fall at home, and admitted to a medical ward with a diagnosis of delirium probably precipitated by urosepsis. The nursing staff finds her to be unwashed, with evidence of faecal soiling. Her son, John, a single man, who called the ambulance, arrives a little later with her tablets. He is unkempt himself. The next day, further collateral history is obtained by the medical staff.

• What else might be going on with the mother?
  
• What else might be going on with the son?
  
• What else do you need to know?

Mrs Antony is ill, and needs careful assessment and differential diagnosis (of fall and delirium). She may have further collateral or underlying diagnoses. Her son may have medical, mental or social difficulties himself that interfere with his ability to care for his mother. It is important to collect information from old notes, previous admissions and other sources.

Mrs Antony is discharged home the next day with planned input from the community rapid response team. Realising that their involvement could be perceived as an intrusion, or even as criticism of his abilities, the team plans to include John in their efforts, and simultaneously to appraise his need for advice and support.

• Who else might be involved in the wider team?

There are many sources of information and help, including the GP, district nurse, social services, private care agencies, other relatives, friends and neighbours.

Unfortunately, Mrs Antony’s daughter died 6 months ago, and John does not allow the team in for their second, evening visit. The social worker reports that he previously stopped regular care input from a care agency after 2 weeks. This event raises several possibilities. He may have problems such as alcohol dependency that he is concealing by restricting access. He may be dependent on his mother’s resources and fear that payment for care will financially cripple him. His mother may well have been protectively complicit in such behaviour in the past, despite its negative impact on her. But if she has developed dementia and lost the mental capacity to appreciate her increasing vulnerability then protective action may be needed to prevent neglect due to denial of access to essential care. This is a complex situation that requires patience and a team-based approach. There may be a need to balance ethical principles of confidentiality with the need to enhance Mrs Anthony’s autonomy. Procrastination should be avoided and the potential need for urgent intervention must be kept in mind.