My Bioethical Opinion is... (7) Ethical Dilemma

Ethical Dilemma
Mrs. Gomez is a 92 year old Mexican American woman who presents to the ED with fatigue, palpitations, and intermittent chest pain. She us a first generation immigrant, speaks English well, lives alone since her husband died. She is accompanied by one of her daughters who lives nearby.
PE identifies atrial fibrillation, elevated pulse rate, elevated BP and abnormal lab values. After stabilization and a MI is R/O a medication review is done. Mrs. Gomez says she has been taking levothyroxine for many years for her low thyroid. She sometimes has problems remembering if she has taken it and so she “just takes another for good measure”. She is not sure how many times a day she actually takes it. “If one pill is good, then three or four are probably better”.
The daughter is horrified and says “that’s it, I work and cannot watch you every minute, you are going to a nursing home where you will be safe”. Mrs.Gomez begins to cry inconsolably and saying “no, no, no, how could you do this to me, your mother?”.
1. What moral principles (autonomy, beneficence, non-maleficence, justice, caring, veracity) are involved for whom?
2. What information might reduce the dilemma?
3. Is there an intervention that would lead to a resolution and be moral for the mother and the daughter?
4. Is culturally appropriate care an issue with this patient situation?

Here is My Answer:

Before ethical decision come the facts. What is necessary to know in the history  presented is whether the cluster of symptoms is related to a confirmed thyrotoxicosis attributed to the overdosage of the thyroid preparation  The symptoms she presented with would not be rare in the elderly not on thyroid.  It would also be important history to know if the patient is prescribed other medications for which she is taking ad lib and not following prescribing instructions. Also one would want to know whether the patient performs satisfactorily and safely all the other necessary activities of daily living. This information is necessary to know whether the patient has the mental capacity to make her own life decisions or needs assistance from surrogates.  Despite what the patient is saying now it also is important to know what the patient has told her family in the past about how she wanted to live if she became elderly or had trouble caring for herself.  Understanding these facts and history is vital for helping the daughter make plans for her mother. 

Whatever the facts and whether the patient has the capacity for continued decision-making and self-care or whether this history requires the use of surrogates, patient autonomy should be recognized and preserved.  Decisions made by others such as the daughter should be made based on the patient’s known and established desires (autonomy) but also in the patient’s best interest (beneficence). 

If the only issue is found to be lack of compliance with a medication prescription and the patient has no elements of dementia, then often simple education regarding medications and dosages, the consequences of non-compliance as well as the error of simplistic but not uncommon thinking such as “If one pill is good, then three or four are probably better” can be explained.  Even the elderly can be educated.  If dementia is the issue, care by others but based on the patient’s previous desires when competent, is the appropriate action.  Often cultural norms play a big role in decision making for the elderly or incapacitated with accepted decision-making and care by the family.  It is not “should this be done?”, it becomes “this is the way it is done.”

This scenario is a difficult one for the daughter, to be obedient to a mother and yet feel responsible for maintenance of her mother’s safety.  Depending on the financial situation, if the patient needs supervision, attempts to provide it at home can be tried and may be less expensive and more tolerable to the mother than living in a nursing home.

Thanks to Ali,Ali for this scenario. 

The one important point to carry away is, most ethical decision-making cannot be made without knowledge of pertinent facts. ..Maurice