Case
A patient aged 97-year-old man living with his eldest daughter and her
family used to regularly visit a general hospital for hypertension and
chronic kidney disease. In January 2016, he developed urinary
incontinence, frequent urination, and constipation, which he had never
experienced before, and visited the emergency department of the general
hospital. He was treated with sennoside tablet 12mg for constipation,
however, his symptoms did not ease until three days after administrating
medicine. So, at the request of his elder daughter, the attending
physician visited the patient and prescribed two tablets of magnesium
oxide 330mg in morning and evening to control defecation. While patients
experienced relief from constipation and urinary incontinence, his
urinary frequency was even prolonged. As blood test showed a high
prostate specific antigen (PSA) level of 139.0 ng/mL, the patient and
his eldest daughter were informed about the possibility of prostate
cancer. Considering the patient’s age, he and his eldest daughter denied
to undergo a thorough examination and choose to monitor the patient’s
condition with regular blood tests. In addition, the patient began using
home care nursing facilities to follow up with his families and to
prevent his Activities of Daily Living (ADL) from deteriorating.
With the help of his eldest daughter, he started keeping records of his
urination frequency and defecation status and managed to take care of
his health. He used to express gratitude to his eldest daughter who was
his primary caregiver. However, sometimes he expressed a rather entitled
attitude, commenting “it is expected for children to take care of their
parents”. Furthermore, he denied using day-care or short stay services,
despite multiple recommendations from his daughter, doctors, and support
specialists. His ADL began to decline prominently, and the frequency of
urinary incontinence was increased. As the daughter was forced to deal
with the patient’s urination, she was tried over time and had difficulty
accepting changes in her father’s condition caused by senility. In
January 2019, we received an emergency call explaining that the patient
suddenly experienced strong back pain and was unconscious. When the
doctor visited the patient’s residence, he regained his conscious back.
The patient and family members were explained about the possibility of a
sudden change in his condition, but the patient assured the doctor that
there was no need for him to go to the hospital. Although the family
wanted to fulfill the patient’s desire, they were worried about
continuing the medical treatment at home and were particularly concerned
about managing such emergencies.
His daughter felt strongly that she needed to care for him, which made
it difficult for her to balance household chores and caregiving. So,
with approval from the patient, they started using day-care and
short-stay services from February 2019. There were some instances where
the daughter also had difficulty accepting the fact that her father was
aging with cognitive and physical decline, so she ended up reprimanding
him for his behavior. Furthermore, she was worried as he refused to get
admission to the hospital even in the emergency. To come up with the
best possible solution, the home care team, which consisted of medical
staff and care managers, discussed with the patient and his family about
his future medical treatment plan. However, as the patient was adamant
about his desire to continue home treatment, it was difficult to come up
with a final solution that could address the desire of patient and at
the same time reduce the burden of care on his family.
In June 2020, we received an emergency call with the complaint of a
fever of 37.8℃ and increase of sputum production after sobbing at
breakfast. At the time of the visit, his physical examination were
temperature 38.2℃, blood pressure 162/93 mmHg, pulse 90 /min, a
saturation of percutaneous oxygen 89% at room air, respiration rate 26
/min and also the presence of lung murmur. So, aspiration pneumonia was
suspected. If physicians had to follow the patient’s wishes at that
stage, medical staff would have considered introducing home oxygen and
daily antibiotic infusion by home care nurses to treat him at home.
However, considering the family’s mental state and their inability to
care for a patient at home, physicians made a comprehensive judgment to
take the patient to the hospital for emergency care. After that, he was
transferred to a recovery hospital for rehabilitation. About a month
later, the family informed that he had been admitted to a nursing home
affiliated with the hospital and there was no further need for a home
visit.