Hastings Center Report

One of the hardest things to do as a house call physician is to ascertain whether older persons can remain in a home situation that seems precarious, if not downright unsafe. We have to balance our concern for their physical well-being against their desire and their right to remain at home. Often this means allowing elderly patients with capacity to live in self-neglectful situations. Determining whether the patient has capacity is not easy, as capacity can wax and wane over time, and variations can be subtle.

Before I ever even met my new patient, Mrs. Rose Grier, I had already received several distressed calls from her daughter Evelyn, who described her mother as irritable, paranoid, and possibly in the early stages of dementia. After this warning, I was surprised to find Mrs. Grier quite interesting and pleasant, and a kind hostess. She was almost eighty years old, born in the South, once widowed and once separated. Currently retired and home-bound, she had worked diligently at various housekeeping and food service jobs to support the college educations of her three children. Evelyn served as her main caregiver even though she lived in another borough, worked full time, and was clearly suffering from burnout.

Mrs. Grier's spacious Harlem apartment was lovingly decorated and full of plants. Framed photographs covered the walls, along with newspaper clippings, Christmas and birthday cards, needlepoint projects, and many drawings, paintings, and other artwork. The pride with which she held on to her independence was evident. She offered me a glass of water and would not take "no, thank you" for an answer, even though it took her more than five minutes to walk to the kitchen and back to bring it to me. I cringed as I saw that she refused to use a cane and moved through her apartment holding on to tables, chairs, and walls. She was a frail woman, her back convex from osteoporotic fractures of her vertebrae and her knees permanently bent from arthritis. It was clear to me that she was in pain, but she declined any pain medications because of a fear of addiction and a profound faith in the fact that prayer was the best balm.

A home attendant helped Mrs. Grier keep the apartment's living room, bathroom, and kitchen fairly clean, although Mrs. Grier resented the attendant's presence and felt it had been forced upon her by her children. Despite her disabling arthritis, she still tried to do the majority of the housework herself. She would not allow the attendant to enter her bedroom, help her bathe and dress, or launder the bed sheets. For this reason, Mrs. Grier was unable to maintain an acceptable level of cleanliness for herself or her bedroom, and this became the main source of the friction between her and Evelyn.

Mrs. Grier was obstinate in other ways, as well. She was convinced that the local electric company was dimming her lights and overcharging her for the electricity, while the heating company did not provide enough heat. She felt both companies targeted her and her neighbors because they lived in a poor neighborhood, and she had created quite a stir complaining about this to building management. My hunch was that her perceptions were not really wrong: worsening eyesight probably made her feel that the lights had indeed been dimmed, and the fact that she used half a dozen space heaters must have made her electric bill seem like highway robbery. However, she would not concede that any alternate explanation of the facts could be valid.

Besides this one fixed delusion about the electric and heating companies, Mrs. Grier's behavior during the rest of the visit was quite appropriate. She was able to inform me of her medical problems; she produced an accurate list of medications, and she seemed to be taking them as prescribed; she even recalled results of screening tests done several years ago. She did not have any health-related complaints and could live with her level of pain. My physical exam confirmed what I had already noticed: frailty, significant curving of the spine, signs of severe arthritis, and poor...