Tuesday, January 5, 2010

Elder Self-abuse Case #1

Consider this scenario, Case Study #1 there are many studied at case conferences...

Grateful for the attention --both man and dog are happy to see you. You feed the dog the doggie treats you always bring. You've taught this happy-go-lucky beast to 'sit', and sit he does, on command, anxious for the dog biscuit you've brought. That done, greetings and skeletal social niceities concluded, the man turns to go back and sit on the couch. As he does so, you notice that his long johns have a spot of feces on it. The room reeks of cigarette smoke, and other smells best left unnamed. The house is now insulated with the 3' of snow that fell, yet the plastic over the windows cannot keep out the cold chill I feel in my heart.

There is evidence of alcohol, and either dementia or delirium, it is hard to say which. The conversation remains befuddled, although you sense from both man and dog that they are as desperate for conversation as a man and dog in the desert. He keeps up a monologue, which requires little response, as he moves frequently from present to past.

The poverty, filth, and clutter scramble for dominance in the place he calls home. His sibling can no longer talk sense to him. The man's mother and brother, seen in tears leaving the house, with it's air leaks, stained carpets, garbage piled high, have been unable to have him sign the papers for a transfer to an Alternate Level of Care, which he desperately needs.

CCAC continues to send a nurse, if the path is shovelled. The local church pays for snow clearing on the driveway. His doctor unable to attend him, recently gone by ambulance to hospital himself. A doctor in Toronto continues to refill his prescription. We know not how.

Last year, knowing his issues, and the informal caregivers who serve his needs as best they can, many with health issues of their own, one went and cleaned his driveway, with help from his four-legged buddy. Most can have a maximum of 15 hours PSW support a week, but one wonders who would be eager to try to serve his needs. Desperation and fear has morphed into anger, violent outbursts to some who try to tell him what to do, and how to run his life.

This time, walking into the unlocked home and bringing him his meds, they were promptly handed over to an eager patient, prone on an unmade bed, covered by a pillow, missing his pants. On the floor, ashes from overturned ashtrays and spilled beer have made a paste coating the carpet. Empty Rx containers, dirty clothes, old pills, papers litter the floor. In the cupboard, 2-4s of empty beer cases are stacked on top of unused incontinence pads.

At another visit, he was sitting on the ratty couch, dog at his side. A shirt on his bony frame, he sat in the overheated, dark, dank house and he was bottomless. A Bell telephone notice, announcing a withdrawal of service, sits on the dirty coffee table. Almost incoherent, conversation is difficult. He could be overdosing, he has a history of addictions, and there is no one to keep him in a routine. This is self-neglect, but his addictions fuddle his mind and rob him of his dignity. Society has failed him. He is less to be censured, as to be pitied. Addictions dig us a hole so deep, all we can see is the terror. Anxious head peers over the edge, but as we cling to that which we know, the addiction: finding the next beer or cigarette, additive personalities cannot seek the light.

A subsequent visit to the home finds fecal matter on pillows and bedding. Gaunt, often appearing delirious, he seems to live in the past and speaking of those long gone. He confuses the immediate past with the long gone family history or anger and addictions and acrimony. Yet he bitterly fights interventions. The room's carpet are cluttered with evidence of overflowed septic systems. The spare room, buried in old clothes and garbage. The laundry room bears evidence of his incontinence on bedding, clothes, and pillows.

Meals on Wheels plastic containers crowds the refrigerator. Soup containers, left on the floor for the dog, have been cleaned out. The two meals he receives, three times a week, fail to tempt his palate. He lives on cigarettes and beer. Formerly an excellent cook, this is tragic. His source of beer and cigs, with no means of transportation, or cash, are a mystery.

One volunteer, speculating to a neighbour about calling the police (who are trained in such matters*) is threatened with violence. We know why, now. But at the time it was a mystery. 

The nurse is called. Reluctant to have him removed to hospital, his neighbours begin to argue that while the man wants to die in his home, responsible, caring, moral human beings cannot leave him in such a condition. Many in the health care professions seem to err on the side of caution. WHile FIPPA, the privacy laws, allow someone to determine his future, there comes a point at which self-harm, in terms of self-abuse, cannot be tolerated by a society that created a free health care program for all citizens equally.

This man cannot be allowed to lie here, with his dirty misshaped finger nails, unwashed, unshaven, nicotine stains on his fingers, with bedsores and likely bacteria and infection lurking in the corners. His dignity and his humanity demand that the community watchdogs: the health care professionals, step up and take over his care.

Eventually, the nurse is convinced to send him to hospital. Hooked up to an IV, he is getting hemoglobins, electrolytes, as well as solid food. He has a catheter; the bag collects his urine below his bed. Heavily drugged, gaunt, he frets over his dog. Weak, with infected bedsores, and still filthy hands and overgrown fingernails, I ponder his fate. A bleak Christmas, indeed.

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