Dementia and A Fib |
Dementia and A Fib - What Would You Do?
A 78 year old female resides in an Extended Care Facilitry Dementia Unit. She has good days and bad but is generally ambulatory while requiring assistance with ADL's. One day she complains of being dizzy and light-headed. VS at the ECF show a lower than normal BP and a HR from 160-180. Her only relatives are distant cousins who do not want to make health care decisions for her. No POA exists.
After ambulance transport to the local ER, she is found to have AF with RVR and started on a Cardizem drip (believing this to be an acute event). No Hx AF. She is admitted as an IP with a 2 MN expectation. She converts back to sinus rhythm after about 6 hours, and the docs try to transition her to oral Cardizem - she refuses any "new heart medicine" because "I have never had any heart problems". She remains in NSR with a rate of 80.
Plans are to do an ECHO and Stress Test, but she also refuses that care. Being that the docs cannot offer anything else, she is transported back to the ECF Dementia Unit after 1 MN.
Is she OBS or IP?
1. Does she even have the capacity to decline medical care? With the Dx of dementia - one wonders. Yet there is no surrogate.
2. Would this be considered a sign out as AMA, even though she also likely had no capacity to sign that AMA document? She was discharged after 1 MN after being admitted with a 2 MN expectation. Is the fact that she refused care and testing "deemed to be AMA"?
3. One could invoke the "better quicker than expected" and consider the pt as IP. But with all the "capacity" concerns, no surrogate, and refusal of all care, I thought there were some interesting discussion points.