Marta is a 73 year-old woman, living in her own apartment. She has early-stage dementia with non-insulin-dependent diabetes (requiring oral medications), mild renal impairment, obesity, and moderate COPD due to previous smoking history. Her son, Ivan, came to visit after a 10-month absence and was shocked by the state of her apartment. He found a charred saucepan on her stove, garbage that had not been taken out for weeks, a foul-smelling cat litter box, and moulding food in the fridge. He took Marta in to her family doctor to express his concerns about her living situation. Her family doctor completed an assessment that revealed, among other things, that Marta has not been taking her medication reliably and that she has deficits in executive functioning. After determining that Marta lacks decision-making Capacity in the areas of health care and accommodation, the family doctor activated Marta’s Personal Directive in these domains. In her Personal Directive, Marta has named Ivan as her Agent (substitute decision-maker). Ivan has to return to his home soon and will not be able to keep an eye on his mother on a regular basis. As a result, he asks the doctor to begin the process to move her into long-term care. The doctor suggests that Ivan take some time to think through the possible options and recommends that he call Clinical Ethics for some guidance.
In your health system, ethicists can receive ethics consultations from anyone, including patients and family members. Responses can take the form of a facilitated meeting with relevant stakeholders or one-on-one conversations to help people think through a difficult situation. In this case, you offer to speak with Ivan about his concerns, help him better understand his role as a substitute decision-maker for Marta, explore the possible options, and help him consider the ethical considerations of each. The goal would be to help him figure out what are the most ethically justifiable option(s) in order to help him figure out how to proceed. A facilitated ethics meeting with relevant stakeholders could be a possible next step, if desired. Ivan agrees with this plan.
In your conversation with Ivan, he tells you that Marta is upset with his interference and does not want to move. The nearest long-term care facility is in a different community, does not accept cats, and will not allow her to smoke. Her spouse died many years ago and her cat is her primary companion. She does not leave her apartment much since she finds walking tiring. She also states that smoking outside contributes significantly to her quality of life. She insists that she is able to cook and provide for herself. Ivan is concerned that she will be evicted if she is thought to pose a fire risk to the apartment building because of her cooking or end up in hospital if she does not take her medications properly. However, he is also her only family and is worried about the damage to their relationship if he makes a decision that she will not like. He is not sure what his options are or which one would be best to pursue.