September 29, 2011

1. September 29, 2011

2. The Case Ruby White is a retired school teacher, aged 75, widowed for 25 years, living independently in a two story home in Burnaby. She has two children. Her daughter, Peggy, the older child, aged 50, a teacher, is married with two teenage children living in Toronto. She also has a son John, aged 48, who is divorced, unemployed and lives Abbotsford. John worked as an administrator in an environmental research firm but his job was made redundant a few years ago. He has not yet found new employment and has been supported financially by his mother.

3. Ruby White is a retired school teacher, aged 75, widowed for 25 years, living independently in a two story home in Burnaby. She has two children. Her daughter, Peggy, the older child, aged 50, a teacher, is married with two teenage children living in Toronto. She also has a son John, aged 48, who is divorced, unemployed and lives Abbotsford. John worked as an administrator in an environmental research firm but his job was made redundant a few years ago. He has not yet found new employment and has been supported financially by his mother. The Case

4. Ruby has a small dog, Trixie, and as a result walks about two blocks twice a day. Otherwise, Ruby spends her days reading the paper, doing the crosswords, and participating in an art appreciation group for senior women. John visits once a month, usually for a home-cooked meal and a cheque ($). Peggy calls from Toronto every week to check in.

5. Ruby has moderate osteoarthritis in the majority of her joints, and due to a life long history of reactive airways, has developed chronic obstructive pulmonary disease (COPD). Both of these conditions remain quite stable; she takes: Tylenol Extra Strength twice daily, Advair 250 mcg one inhalation twice daily, Spiriva one inhalation daily and Accolate one tablet twice daily. She occasionally requires antibiotics and oral prednisone for her COPD, her last exacerbation was about 6 weeks ago. She had cataract surgery two years ago; she is hard of hearing but “won’t consider hearing aids”; and she is “down to 6 of her own teeth” with the remainder false.

6. Recently, Peggy has been worried about her mother’s memory and is wondering whether it might be a sign of early Alzheimer’s disease. Ruby seems increasingly forgetful, repeating herself often in her phone calls and forgetting her train of thought. Ruby has stopped going to her art appreciation group and commented that people are not friendly and the activities are boring.

7. Peggy is also worried about her mother’s hearing. Peggy often has to repeat what she is saying and her mother frequently responds to her questions with strange answers. Ruby also complains that people on television talk too fast these days and the shows aren’t as good as in the old days when people had good diction. Peggy is wondering if her mother’s hearing problems are contributing to her confusion.

8. Peggy had to contact the hydro company the other day because Ruby had not paid the bill. Ruby continues to drive; however, she has had several minor accidents and on one occasion became so lost in her own neighbourhood that she had to ask for help. When questioned about her memory, she is quite defensive and even a little argumentative. Peggy has called John to see if he has the same concerns; however, he brushes it off and says it’s nothing more than “forgetfulness of old age” and thinks “she is doing fine”.  

9. Peggy is also concerned about Ruby’s recent complaints of worsening hip pain. Her mother has attributed it to arthritis, but it seems to be progressing more quickly than one would expect. The fact that her mother complained tells Peggy that it must be pretty bad; her mother is known for being stoic. One Sunday, Ruby seems unusually down and says she is considering giving up Trixie because she can no longer walk her. Peggy is very concerned and plans to fly in from Toronto and see for herself what exactly is going on.

10. TEAM A CASE SCENARIO

11. Before Peggy can clear her teaching schedule and book a flight, Ruby has fallen, broken her hip and was admitted to a hospital. You are the team on the geriatric ward. What is your care plan?

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19. TEAM B CASE SCENARIO

20. Before Peggy can clear her teaching schedule and book a flight, Ruby has had a stroke and was admitted to a hospital. You are the team on the geriatric ward. You are the team on the geriatric ward. What is your care plan?

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28. SCENARIO TWIST #1 TEAM A

29. Post-operatively, Ruby had a left-hemispheric stroke. After three weeks in the hospital, Ruby is anxious to return home. She still has mild right hemiparesis but has recovered enough from both the stroke and the hip fracture to walk with a four-wheeled walker. John tells the care team that he will move in and look after her. He still has not found employment and as he “has been looking after her for years he can manage everything that she needs”. Although this is one option, Peggy reports ongoing concerns about her mother’s cognitive function. Her care team also has concerns as to whether Ruby will be able to manage, even with John’s help.

30. What is your discharge plan for ruby?

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38. SCENARIO TWIST #2 TEAM B

39. Two nights after admission for her left hemispheric stroke, Ruby, in a delirious state, attempted to get out of bed unassisted; fell and fractured her right hip. After three weeks in the hospital, Ruby is anxious to return home. She still has mild right hemiparesis but has recovered enough from both the stroke and the hip fracture to walk with a four-wheeled walker. John tells the care team that he will move in and look after her. He still has not found employment and as he “has been looking after her for years he can manage everything that she needs”. Although this is one option, Peggy reports ongoing concerns about her mother’s cognitive function. Her care team also has concerns as to whether Ruby will be able to manage, even with John’s help.

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47. With community care in place and John committed to living with his mother, Ruby returned home. Peggy also returned to Toronto and continued with the weekly phone calls. Things seemed to be going well until about six months after discharge. At that time, Peggy became more concerned because when she tried to phone her mother, the phone was seldom answered and when it was, she was only able to speak to John. He was rather vague about Ruby’s health and said that everything was fine.

48. Peggy decided to contact Ruby’s neighbour, Maureen, who informed her that she had not seen Ruby in a week or so, and when Maureen went to deliver some home baking, John would not let her in the house. Peggy then decided to contact the community care case manager about her mother’s status. The community care case manager reported that the home care nurse had documented that Ruby was losing weight, her hygiene was deteriorating, and was refusing to let home-making services into the house.

49. A few weeks ago, John had reduced her home care services to only those services covered by Ruby’s insurance. The home care nurse questioned whether Ruby was taking her medications as she seemed to be increasingly isolated and paranoid. The community care case manager brought up the topic of capacity with Peggy. Team A:Describe how you would work as a team to address Ruby’s current situation?

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