Honoring Patients' Wishes for Less Health Care FREE

My patient was a 99-year-old nursing home resident with advanced dementia and very little awareness of her surroundings. She was well known to me, having been a resident in this nursing home for approximately 10 years. While making routine rounds at the nursing home, I was advised that she had developed some discoloration and skin breakdown of her feet. On examination it was obvious that she had developed gangrenous changes in both feet, an ominous sign in this elderly woman. I contacted her niece and nephew who served as co–powers of attorney and discussed treatment options with them. Recognizing the seriousness of the condition and that their aunt had enjoyed almost no quality of life for many years, we agreed that only supportive comfort measures should be implemented.

On returning from vacation 2 weeks later, I was distressed to discover that nursing home administrators and nurses had gotten permission from an on-call physician in my absence to send the patient by ambulance several times per week to the local hospital-based wound care center for treatment. This particular nursing home, which is deservedly known for giving excellent care, was reacting to a recent government fine after a family member of another resident had surreptitiously brought some fried chicken to the facility, leading to an accidental aspiration death. The nursing home administrators felt that they could not risk another investigator claiming that they could have done more for the patient. Instead, her futile trips to the wound care center involved uncomfortable transfers and painful debridement procedures with no change in the inevitable outcome of death.