Legal - Managing disputes about medical treatment decision-making - Cast Study

Case Studies: Managing Disputes About Medical Treatment Decision-Making

Bill and Rebecca

Bill is an 85 year old with coronary heart disease in residential aged care. Late one Saturday evening Bill feels short of breath and presses the call button for the nurse. Sarah, a recent nursing graduate, is one of the nurses on duty. She assesses Bill and determines his oxygen saturation is slightly lower than usual. Given Bill has a PRN order for oxygen she administers this and waits 5 minutes before reassessing. Bill tells her his breathing has improved, but he feels a bit dizzy. His oxygen saturation remains low. As it is the weekend, Sarah decides not to inconvenience the home’s GP. She tells Bill there is nothing to worry about and that she will check in on him a little later. Her nursing colleagues and the Registered Nurse After Hours Coordinator (RNAHC) are busy dealing with an emergency, and she is unable to discuss Bill with them immediately. 

Due to the emergency, Sarah spends the rest of the evening managing other residents mostly on her own. When she checks on Bill a few hours later he is experiencing serious breathing difficulties and cannot communicate. Sarah immediately replaces Bill on the oxygen (as he had removed the mask), and calls an ambulance. The paramedics assess Bill, initiate a higher dose of oxygen, gain IV access. Bill is transfered to hospital, where a respiratory physician determines Bill has pneumonia.

Rebecca, the facility’s RNAHC, contacts Bill’s daughter Emily and explains what has happened. Emily is furious that a GP was not called when Bill first experienced breathing problems. She requests a meeting with the facility’s management the following day.

Rebecca meets with the Facility Manager and Sarah to discuss the incident. They check the facility’s policy on managing deteriorating residents. They conclude that Sarah acted contrary to the policy by failing to escalate Bill’s condition to the RNAHC and the GP in a timely manner. She should also have checked on Bill every 30 minutes instead of the hours later. Policy also says training on managing deteriorating residents is to be provided to all staff annually but no training exists. The Facility Manager was unaware of this, having only recently started in her role.

When Emily meets with the Facility Manager and Rebecca they acknowledge that Bill’s deteriorating condition should have been escalated to a GP earlier, and apologise to Emily and Bill for their mistakes. The Facility Manager commits to developing best practice training for staff to improve the management of deteriorating residents, as well as improving the existing policy. She also advises they will review and optimise after hours clinical staff to improve service delivery when emergencies arise. Emily appreciates the apology and is satisfied with those proposals. After successful inpatient treatment Bill returns to the facility.

Kim, Linh and Anh

Kim is a 76 year old woman in residential aged care. Five years ago she was diagnosed with late onset schizophrenia, characterised by delusions. She experiences disorientation, confusion and short-term memory deficits, which have deteriorated further in the past 3 months. She is accommodated in a secure wing at the care facility as she requires constant supervision, and management of her wandering behaviour. Kim receives weekly visits from her granddaughter Linh, and enjoys her company. Linh is satisfied that Kim is receiving appropriate care.

Kim has less regular contact with her brother Anh, who is concerned about Kim’s care. He believes that she is isolated unnecessarily, and that the home is understaffed. He has argued with the staff, who he says are denying Kim traditional Vietnamese medicine to manage her health conditions. Kim has a history of paranoid delusions relating to Anh,  which have caused her to fear him, and she appears distressed when he visits. Linh and Anh have a history of conflict with each other, and Linh tells Anh to stop contacting Kim. She asks the facility to block Anh’s calls.

Health care decisions are required for Kim to ensure she receives appropriate treatment for new health conditions, in particular suspected skin cancers which need to be biopsied and possibly removed. Kim’s GP has advised that due to her cognitive condition Kim is unable to make simple or complex personal decisions, including decisions about health care. Linh and Anh have provided conflicting treatment instructions to the facility and GP due to their lack of consensus.

The facility’s Residence Manager is aware that the current decision-making process is in effective, and arranges a family conference, in accordance with the facility’s dispute management policy, to try to reach an agreement about Kim’s treatment. During the conference Linh and Anh argue, and Anh becomes frustrated and leaves. As the dispute is unable to be resolved informally, it requires escalation to the State’s Civil and Administrative Tribunal for the appointment of a guardian to make health care decisions for Kim.

The Tribunal will determine whether Kim has capacity to make health care decisions. If she does not have capacity (which is highly likely on the facts in this case), the Tribunal would likely appoint a guardian. The Tribunal would determine whether either Linh or Anh are appropriate to be appointed guardians, or whether someone else, such as the Public Guardian, should be appointed. The appointment of a guardian will clarify for the facility’s staff and Kim’s medical practitioners who is the legally recognised substitute decision-maker for Kim’s health care and medical treatment.

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Page updated 13 September 2018