Assignment Task:
Mary is a resident in a nursing facility-and has been for the past 5 of her 87 years. Most of the time, she is withdrawn into her own little world, although she shows occasional signs of being alert to her surroundings, sometimes appearing to be confused by them. Her physical appearance is generally good. She is neat and clean, more due to the care and effort of the facility staff than to her own efforts. Her hair is brushed neatly, and her clothes are freshly laundered and pressed. She spends her time in a wheelchair because an arthritic condition makes it difficult for her to walk.
Mary does not participate in many of the organized activities of the facility, in spite of valiant efforts by the staff to get her to do so. She seems content most of the time to keep to herself, although her favorite spot is near the nurses' station where she is surrounded by activity. How much of it she actually absorbs is unknown, but she prefers to be at the hub of things. This lack of cognitive ability has come on gradually over a number of years, and her doctors have not felt the need to apply a specific diagnosis. Of more concern to them is her history of at least one heart attack, late-onset diabetes, and arthritis that has virtually destroyed her hips.
This is not the Mary we would have seen a few years earlier. Let us look at her background to better understand her and how she came to be a resident of the nursing facility. She has led what some would consider a difficult life. Married to a construction worker who often had to travel considerable distances to work sites and came home only on weekends, Mary bore most of the responsibility for raising four children. She was a very strong-willed, self-reliant person. That is important in understanding the extent of lifestyle change she had to overcome in her later years.
After being widowed before she turned 60, she continued to live alone in the family home for a number of years. Eventually, however, it became clear that she could not care for herself safely, largely because of the advancing arthritis in her hips. She agreed to move in with her daughter and son-in-law, a first step toward losing her independence. The situation was amicable. She had a room of her own but was fully included in the family's affairs, and she assisted in some chores, particularly cooking. Given the security of the living arrangements, she was able to continue knitting, sewing, and crocheting, something at which she was very talented. It allowed her to feel that she was contributing and useful.
However, the time came when Mary became forgetful and occasionally used poor judgment, making it unsafe for her to use the cookstove. She also posed a threat to herself should she fall or wander, and she could not be relied on to remember to take her medicine. She needed nearly constant supervision for her own protection. Because the daughter and son-in-law operated a business on the premises of their home, they were able to provide that supervision longer than most, but eventually even they had to face the reality of placing Mary in a more protective setting, probably a nursing home.
They were fortunate to find an excellent facility only a few miles from their home. It provided multiple levels of care and was affiliated with a nearby hospital. It offered the further benefit of being close to her former neighbors and friends, a fact made even more important because her remaining three children all live out of state and are unable to visit regularly.
Thus, in spite of the feelings of guilt that are experienced by most families when faced with placing a loved one in institutional care, Mary was admitted to the Mountainview Health Care Facility.
Because of her age and lack of personal finances, Mary's care in the facility is covered by a combination of Medicare and Medicaid. Her essential needs are met, and although there are few extras, her needs are modest. Family members provide new clothes and personal items as needed. Some items, such as eyeglasses and dentures, are covered by Medicare or Medicaid, although the process of approving the expenditures can sometimes be lengthy and cumbersome. The time that approval takes is a nuisance for Mary-especially since she has a habit of misplacing or losing her glasses and dentures. For the staff at Mountainview, however, it is more of a feeling of frustration. They want the best for all of their residents and would rather be spending their time caring for them than doing paperwork. However, they also realize that Mary brings some of on it by her own actions, and they sympathize with the staff processing the paperwork on the other end.
Mary, as her cognitive ability and sense of reality have progressively decreased, has slipped ever more into her own imaginary world. That has both advantages and disadvantages for the facility staff. On the plus side, she usually requires little actual care, other than seeing to it that she takes her medication and that her heart condition and diabetes are monitored and treated as necessary. On the other hand, her lack of reality makes her difficult to live with. She resents roommates, thinking of her room as the home she remembers. For a long time, she refused to attend any of the many group activities arranged by the facility staff. After much questioning, they eventually found that she thought that all of those events were funerals, and she dislikes funerals.
Mary's retreat into her imaginary world has been harder on her children. She no longer recognizes them and has no concept of how often they visit. They have increasingly felt a mix of gratitude for the excellent and humane care provided by the facility staff and a sense of loss because of their decreased involvement in her life.
However, that situation has recently taken a significant turn, placing them in a position of making a difficult, but important, decision on Mary's behalf. The arthritis has caused her hips to deteriorate to the point where she not only is unable to walk, but is uncomfortable even sitting in a chair or wheelchair. They decided to approve the surgery for hip replacements to make her more comfortable.
A. Should Mary's family members authorize double hip replacement?
B. What factors should be considered?
C. Who else, if anyone, should be consulted?
D. What are the implications of that decision on the parties involved: Mary, her children, the facility staff?