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GPs buried under trusts' workload dump

Family feuds over father's bad habits

Case history

William, 74, is a widower and lives alone. He has been a heavy drinker and smoker for years, has recently had a number of falls and complains of vertigo. He is essentially housebound, but has three caring daughters who visit most days. One of his daughters, Sarah, has asked him to go and live with her, but he does not wish to be a burden. He has ischaemic heart disease and is on regular medication. William comes in with one of the daughters after a fall. As he can't get out on his own, the third daughter has acceded to his demands and brings in cigarettes and whisky. The others say she is killing him. What should you do?

Dr Abayomi McEwen

'Can they all find a compromise they can live with?'

First, I would make sure his fall had not caused him any physical damage needing immediate treatment or referral. Next I would review his medication. Excluding an iatrogenic cause for his falls is extremely important. Time pressure and lack of expertise makes me feel I do not always sufficiently consider the consequences of practising evidence-based medicine, especially in older patients. In my view every health professional who prescribes medication should have access to an experienced clinical pharmacist.

The third issue is whether I have worries about William's mental function, and his ability to make decisions about his health. A referral to a psychiatrist for the elderly might be in order to clarify this aspect and perhaps support us in defending his autonomy.

But if I can be sure William understands the increased risk to his health due to his cigarette and alcohol consumption, negotiation with his daughters would be in his interest.

At this point I would try to persuade the daughter who brought him to have a talk with her sisters. They need to consider his wishes and what his quality of life might be if these substances were stopped. They need to see things from William's point of view.

I would leave William and his daughter with the idea that they needed to resolve this and try to find a compromise they could live with. I cannot get involved in a family row.

Finally, I would make detailed notes and try to speak to William's GP about the consultation.

Dr Michael Crawford

'Is it fair to stop this elderly man's simple pleasures?'

My gut reaction would be to think how right this daughter is. William's cigarette and alcohol intake is contributing to his physical decline and if he continues to imbibe at this rate he will not be a concern for his daughters much longer. On the one hand is a daughter dutifully acceding to his wishes and feeding his habits but on the other is an elderly man who wishes to enjoy these simple pleasures no matter how deleterious to his health. Is it fair to stop him?

This is an opportunity to take a detailed history from William regarding what has been going on over the past few months. I would try to glean enough information to decide if these falls are fits, ischaemic/iatrogenic falls, or due to deteriorating mobility and senses. William needs to be advised to attend to his health more than he currently does or risk serious injury.

Is he aware of alert systems worn around the neck as provided by Age Concern and other organisations? Perhaps if he agreed to this measure his family would feel happier about him staying at home.

By all reckoning it appears that William is lucid, determined and has full capacity to decide his own destiny. If this were not the case I would involve the local consultant in psychiatry of old age to perform an assessment. It may appear to everyone around him that moving in with family would be safer for William, but unfortunately the most important person disagrees.

I would do my best to reason with William and ask him to consider reducing his alcohol and cigarette intake if he wishes to lower his risk of falls.

As for the daughter that attends with William, I would admit to my gut feeling but would try to make her aware of her sibling's reasons for continuing to provide William with harmful substances ­ her sister may feel a duty to obey her father or to grant him his wishes in his golden years and would feel guilt if she refused to carry on.

Dr Claire Bailey

'I must respect his autonomy if he is mentally capable'

My responsibility is primarily to William. It is my duty to respect his autonomy and decisions about his future care as long as he is deemed mentally capable, despite his worsening physical health.

As William's doctor I would initially need to exclude any new pathology to explain his recent deterioration.

There are several organic conditions that present with falls and vertigo. Some of these may be excluded with simple investigation and treated, for example a middle ear infection.

I would also assess his competence to understand his medical problems and the potential future consequences. This would involve discussing the amount of alcohol he was drinking and relating that to his falls.

I could only offer advice to both William and his relatives with regard to alcohol consumption and smoking. I would not be able to stop his supplies arriving or insist he modifies his habits. It is unfair of the daughters to accuse one sister of 'killing him' by delivering his supplies.

I am sure he would be able to persuade a neighbour to do this or even the local supermarket home delivery service.

William has made it clear he wants to stay at home and this should be respected if possible. He may benefit from an assessment by the occupational therapist at home to make his environment as safe as possible.

William is in a fortunate position to have three caring daughters. As his condition deteriorates he may need to rely on them more for support. My role in this situation is to remain neutral. I would keep my discussions open and avoid apportioning blame.

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