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Mr H, aged 87, was admitted to hospital with a two-week history of generally feeling unwell.
His daughter, Mrs A, lived nearby, visited Mr H most days and was listed as his next of kin. She had noted him to be slightly confused, to have poor appetite, and a cough.
She informed the nursing staff that he required assistance with most activities of daily living. This support was provided with visits from trained carers. His cognition was good with only slight short-term memory loss.
Mr H also had a son Mr B, an engineer, who lived some distance away but usually visited about once a fortnight. Mr B’s partner was a practising physiotherapist who would accompany him on these family visits.
While Mr H had a number of co-morbidities, namely hypertension, Type 2 diabetes and mild cardiac issues, his daughter Mrs A stated that she felt his overall health was good, taking his age into account.
Mr H was admitted under the care of Dr Q, who had recently taken up the post of consultant physician in the hospital. Dr Q had extensive experience as a physician elsewhere and this was first consultant position in Ireland.
At the time of admission Mr H was noted to be mildly dehydrated, to have moderately raised blood sugars. Clinical examination and radiological imaging resulted in a diagnosis of lower lobe pneumonia and intravenous antibiotics were initiated. There was no evidence of urinary tract infection (UTI) and he was not constipated.
Mr H responded well, initially, to his treatment which was augmented with physiotherapy and dietetics. His appetite improved and the daughter, Mrs A, noted that he appeared less confused. However, his respiratory symptoms were not improving and the results of microbiology cultures highlighted a need to adjust his antibiotic therapy on a number of occasions.
After a number of antibiotic modifications Mr H’s overall health improved and plans were made for his discharge to a respite facility.
His son Mr B visited regularly during this time.
Unfortunately, two days prior to discharge Mr H developed severe vomiting and diarrhoea which required isolation. Despite further antibiotic interventions Mr H’s symptoms did not improve. He became very weak, dehydrated, and declined food and drinks. His confusion worsened and his daughter requested a meeting with Dr Q to discuss her father’s care. Mr B and his partner also attended this meeting. Dr Q recommended that more potent antibiotic therapy be commenced and nasogastric (NG) feeding. Mrs A said that her father would never have wanted such interventions. She said that in all of her visits to him he had asked her to ensure that he was not kept alive by inappropriate medical means. However, at this point Mr H was completely confused and unable to respond to any questions regarding his care.
Mr B’s partner intervened to say that she disagreed and felt that a short trial of Dr Q’s recommendations was reasonable. Her partner Mr B agreed and Dr Q commenced potent antibiotics and inserted a NG tube.
Mrs A remained with her father over the following days. She could see no improvement in her father’s condition. She became very distressed and implored for all interventions to be withdrawn. Nonetheless Dr Q stated that it would take time for her father to get better. Her brother supported Dr Q in this decision.
Sadly, one week later Mr H died.
Two months after Mr H’s death the hospital received a letter of complaint from Mrs A regarding the care of her father. She stated that at all times her wishes were ignored by medical staff and that as a result her father’s dignity was non-existent. In her letter she requested that the hospital apologise to her and explain why her wishes were ignored. She felt that there should have been involvement of other hospital personnel for advice such as care of the elderly or palliative care teams. She said that she was now aware that an advocate could have been used to support all parties. She never wanted another family to have such a terrible experience.
Dr Q was very distressed by the letter. Being in post only a short period of time he was fearful of the consequences, particularly with the mention of the IMC. He felt his clinical care had been appropriate. Colleagues advised him to contact Medical Protection for advice as he was a member.
A Medical Protection medicolegal adviser contacted Dr Q and noted that he was unfamiliar with the hospital’s complaints policy which were then outlined to him. With the adviser’s assistance, his statement, and the review of patient notes Dr Q drafted a letter for the hospital to forward to Mrs A. He also offered to meet with her, accompanied by the hospital’s complaint’s officer and she accepted this offer.
Prior to the meeting, Medical Protection advised Dr Q on how to converse with Mrs A and directed him to the appropriate legislation, IMC guidelines, Medical Protection learning resources, and HSeLanD resources.
Noting how distressed he had found this incident, Dr Q’s Medical Protection adviser signposted him to the independent counselling care.
When the meeting took place Dr Q explained to Mrs A that all of his intentions had been in the interest of her father and acknowledged that he could have considered consulting with other clinicians. He also noted that, as he was new to the Irish healthcare system, he had not been aware of the role of advocacy. He assured her that he had now familiarised himself with all of the legislation and ancillary support services available. The Medical Protection team explained to Mrs A that a next of kin does not have a legal status in decision making, which she had not been aware of. Exceptions to this would be if they had been made an enduring power of attorney or had been appointed a decision-making representative by the court.
Dr Q apologised for the distress he had caused to Mrs A and the issue was resolved.
HSE National Consent Policy - Corporate
Assisted Decision-Making (Capacity) Act (2015) in HSeLanD (enacted in 2023)
MPS has a wide range of resources for educational purposes. Resources, training and events (medicalprotection.org)