Don't I count?

Alice is a seventy-year-old woman with metastatic breast cancer undergoing monthly chemotherapy treatments. Although she lives alone, her granddaughter, Louise, visits her several times a week and helps her do things she can no longer do for herself. Louise usually shops for Alice, washes her clothes, and cleans the house. In addition, she takes Alice to all her appointments. As Alice's treatments continue, Louise finds that Alice requires more frequent help of every kind. Alice seems to have increasing difficulty moving about her house and needs more help with her personal hygiene. Louise discusses with Alice the possibility of hiring someone to look after her and stay with her during the day and some evenings while Louise goes to work. Alice refuses to entertain the suggestion, insisting she is capable of taking care of herself. Just before a routine office visit Louise tells the nurse, Rebecca, that Alice appears increasingly weak and has difficulty bathing, getting in and out of her wheelchair, and fixing her own meals. Louise explains that she works as a musician in a nearby city and keeps very irregular hours, which makes it difficult for her to help Alice with more than a few simple routine daily activities. She worries constantly that Alice will fall and injure herself. Other family members or friends are either unwilling or physically unable to share the responsibility of Alice's care. Louise's constant worrying and exhaustion have begun to affect her job performance and she occasionally misses rehearsals on days when Alice needs extra help. Rebecca agrees that Louise must have help taking care of Alice, at least until Alice completes these aggressive treatments. She suggests they approach the doctor about their concern. The two women explain the predicament to Dr. Ramsey, the oncologist caring for Alice, and ask him to order a consult for a home health nurse and/or meals-on-wheels. Alice immediately protests, "No, absolutely not. I feel well enough to take care of myself. Louise should go to rehearsals and not worry about me. If I fall, it's my problem, not Louise's. " Dr. Ramsey asks Alice if she feels positive that she can manage by herself. Alice replies, "I certainly can. I don't want to hear another word about it. " Continuing to address Alice, Dr. Ramsey says, "Well, if you say no to home health care the answer is no. My patients have the right to make their own decisions. " Despite Alice's wish to hear no more about this, Louise urges Dr. Ramsey to reconsider, emphasizing that Alice could easily fall and break her hip if left alone, which would set her health back tremendously and force Louise to leave her job to take over Alice's care full time. Dr. Ramsey replies, "I am sorry about your situation, but I cannot, in good conscience, try to persuade a patient to accept a service she clearly does not want. " Louise tries to urge Dr. Ramsey again but he ignores her and only acknowledges comments from Alice. Rebecca tries to support Louise's concerns, but the doctor ignores her as well. Later, after Alice and Louise leave the office, Rebecca tells Dr. Ramsey how frustrated she felt when he would not listen to their concerns about Alice. He reiterates that Alice is competent to make her own decisions and that she has a right to refuse home health care. He says he felt the need to focus on his patient rather than Rebecca or Louise because they seemed to be talking about the patient as if she were a child: leaving her out of the discussion. He says, "Someone in that room needed to show Alice that they recognize she is still in control of her affairs. " Rebecca tells Dr. Ramsey that at the very least, he should document Alice's refusal of home health care in the chart in case Alice does injure herself. Is Dr. Ramsey right to see this decision as belonging solely to Alice? Commentary Dr. Ramsey is very intent on doing the right thing for his patient. …