Question

CASE 66 See Me, Hear Me:The Case of the Disempowered Older Adult Kelly Niles-Yokum The administrators and staff of Zen Hospice are preparing a room for a client who is currently receiving in-home services from Zen staff. The client, Mrs. Smith, is a 96-year-old widow who was diagnosed with terminal cancer. She is nearing the end of her illness and is expected to live for another month, at the most. Zen Hospice was contacted by Mrs. Smith’s daughter, Ann, who has been caring for her mother for several months in her mother’s home. Ann and her mother have a very good relationship, in general, but things have become more intense over the last few weeks as it has become clear that Mrs. Smith is at the point in her illness where she requires more help than her daughter can provide. Luckily, Mrs. Smith has her affairs in order. Her grandson, John, who is 46 years old and lives 3,000 miles away, visited a few months ago to assist with the process. Mrs. Smith granted John durable power of attorney and identified Ann as her health care proxy. Mrs. Smith and John enjoy a very close relationship and she confides in him about many things. One thing she is very clear about is her wish to die at home. While Mrs. Smith has nothing in writing about her preference she has been very vocal with everyone in the family. During a recent conversation with her grandson she stated, “Johnny, I trust you. You know how important it is that I am here when I die. I’ve lived my life here, my memories are here.” John assures her that she will be able to die in the home she has lived in for over 40 years. Because Mrs. Smith’s illness has taken a turn for the worse and she now requires constant care, Ann made the decision to bring hospice into the home. Ann assures the family that this is the best decision for everyone involved and explains that hospice is, in fact, holistic care and that the whole family will benefit from the experience, including her mother who will be able to remain in her home. After Ann tells her son, John, about the hospice nurse coming to the house to help and about the relief she feels, John feels better knowing that both his grandmother and his mother are being cared for. As the administrator of Zen Hospice you have familiarized yourself with Mrs. Smith’s case and meet regularly with the staff assigned to her and her family. You are aware of Mrs. Smith’s wishes to die in her own home and have spoken to several members of the family including the grandson, John, about Mrs. Smith’s end-of-life decision about where she would prefer to die. A few weeks later, during the most recent weekly team meetings, one of the nurses mentions that Ann has expressed an interest in temporary residential care for her mother. You ask for more information from the staff assigned to Mrs. Smith’s case. All are in agreement that Ann would like to move her mother to their residential facility for short-term care. You inquire about the end-of-life preference expressed by Mrs. Smith to die at home. After listening to all of the team members you decide that this is the right course of action and give the green light for the move, which will take place the following morning. When you arrive the next day you are briefed by the team and then take some time to visit with Mrs. Smith and her family. You are surprised to find that, while Ann seems to be relieved by the move and expresses her appreciation, you are not able to have a conversation with Mrs. Smith because she is at the point in the dying process where she is not fully aware. She seems confused and her breathing has become apneic. It is clear that death is imminent. While you are assessing the situation, John calls Ann and from her responses it is clear that he is upset by the decision to move his grandmother from her home. Discussion Questions 1. What are the main facts of this case? 2. Describe what is going on and what the main issues are. 3. Do you think the actions taken by the hospice staff were well-intentioned? If yes, why? As evidenced by what? If no, why? What evidence leads you to believe this? 4. What was the role of the administrator in this case and what was her responsibility? 5. Is there anything the administrator should have done differently? If yes, what? If no, why? 6. Throughout this case we hear from Ann, from John, and from the hospice staff. Who should have been the voice of Mrs. Smith? 7. Whose interests were prioritized and why? What were the consequences of not “hearing” Mrs. Smith in her final days? Why did the staff make their decisions based on Ann’s needs and not Mrs. Smith’s wishes? 8. Discuss the ways in which Mrs. Smith’s wishes could have been fulfilled. 9. Mrs. Smith was not exactly given a voice in this narrative and was easy to ignore. Why do you think the case was written this way?

Answer 1

The main facts are that Mrs. Smith’s wishes is she wants to die in her home.

Mrs. Smith has assigned Johnny as her durable power of attorney and Ann as her health care proxy. Ann has temporarily placed Mrs. Smith in the residential short term care without consenting with John. Mrs. Smith’s wishes is to die in her home, Johnny knows that her wish is to die in her own home but he lives three thousand miles away, Ann is the one caring for her and has made a temporary decision to place Mrs. Smith in the residential facility short-term without letting John know. Her death is very near and this is not a good idea to do being that Mrs. Smith wants to pass away in her home. Now that Johnny has found out the temporary decision he is upset that his mother Ann has made that decision.

The staffs intention may have meant to be well intentioned but her wish was to die at home, although it is not written everyone knows this. I honestly don’t know why they agreed to bring her in the short term care when it was already hospice assistance at her home being provided.

The role of the administrator was to make sure Mrs.Smith of all people are informed of what is taking place. Now that the administrator has already made the decision and now wants to have a conversation with her after the fact of placing her Mrs. Smith now cannot speak or understand and have a conversation for the matter.

The administrator should have spoken with Mrs. Smith letting her know why they are making this decision before finalizing and making this decision to place her in the short-term care.

John should been the voice for Mrs. Smith with him being the durable medical power of attorney. Ann interests were prioritized because she was the health care proxy.  

That this would fall on Johnny and the family for knowing what her wishes wanted to be in her last days. The guilt of not following through with her wishes.

Probably because Ann was Mrs. Smith’s health care proxy and Ann was the one whom the facility and staff dealt with the most. They probably didn’t respect Mrs.Smith’s wishes because it was not in writing. Mrs. Smith’s wishes could have been filled if Ann would have remained her hospice care in her home. Because Mrs. Smith was very ill and probably were not able to talk as much due to her illness.