Third pneumonia and a family that disagrees
Mrs Doyle, 88, has advanced Alzheimer's disease and has lived in residential aged care for two years. She is now febrile at 38.9 C, tachypnoeic at 28/min, with SpO2 88% on room air and coarse right basal crackles; she is drowsy but rousable to pain. This is her third chest infection in six months; the last two led to hospital admission and a week of intravenous antibiotics. Her daughter, who holds enduring guardianship for health decisions, has told staff repeatedly that her mother 'never wanted to be kept going by machines'. Her son, who lives interstate, has just phoned the facility and insisted on 'everything possible'. There is no completed advance care plan or goals-of-care document. The registered nurse pages you at 5:40 pm asking you to 'write up antibiotics and order the ambulance like last time'. The practice closes at 6 pm.
1. What do you do in the next 30 minutes, clinically and communicatively?
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First, make a clinical judgement: she is unstable - SpO2 88%, respiratory rate 28, febrile, drowsy. Whatever the goals of care, she needs oxygen and assessment now, and the argument about place of care must not delay treatment.
Second, control the communication. Ring the son back yourself before the ambulance arrives if possible, and say plainly: 'I am examining your mother now. I will speak to you again within the hour with a plan.' Speak to the daughter, who holds guardianship, and ask what she understands her mother's wishes to be. Speak to the facility nurse to find out what Mrs Doyle has said or indicated over two years - aged care nurses often hold the most relevant evidence of a person's wishes and fears.
Third, treat in place if that is consistent with her values: oxygen, positioning, analgesia, and antibiotics if treating the infection is consistent with her goals. Many families accept 'treat the infection but do not send her to hospital'. Arrange an urgent after-hours review or a phone discussion with the on-call palliative care service.
Document contemporaneously. Do not write 'for everything' or 'not for resuscitation' without an explicit, recorded discussion.
2. How do you structure the family discussion, and what legal and ethical framework guides the decision when the children disagree?
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Structure: ideally a single meeting, by phone or in person, with the daughter and son together if possible, plus the facility nurse. Introduce the purpose: 'We need to agree what your mother would want, not what we can do.' Establish what she was like before the illness, and ask each child for a specific example of something she said about being kept alive or going to hospital. Ask the daughter what her understanding is as guardian.
Legal and ethical frame: the decision must be made in Mrs Doyle's best interests using substituted judgement - what she would have chosen - not what the family prefers. The daughter is the decision-maker for health matters if her guardianship is registered and covers this; the son's views should be heard and documented, but he does not hold decision-making authority. If conflict persists, seek advice from the guardianship body or a clinical ethics committee; a decision does not require everyone's agreement.
Name the disagreement openly: 'You two want different things for your mother, and that is common in families. My job is to keep her comfortable and to follow what she would have wanted.'
A time-limited trial is often the workable compromise: antibiotics and oxygen for 48 hours with pre-agreed criteria for continuing or moving to a palliative pathway.
3. What documentation and system changes do you put in place afterwards?
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Document: the clinical findings, the discussion with each family member, the legal basis for the decision (guardianship, substituted judgement), who was consulted, the agreed plan including what to do if she deteriorates overnight, and the after-hours contact. Give the facility a written plan - nurses act on what is in the notes, not on what was said on the phone.
Complete an advance care plan and goals-of-care document for the future. This admission is the trigger; the next one may come at 2 am on a Sunday. Use a recognised form, ensure the daughter signs as guardian, and place a copy in the notes and with the medication chart.
System: ask the facility to flag residents without a goals-of-care document at their monthly review. Agree a process with the after-hours service so that the same conversation is not repeated by a different doctor each time. Raise it at the practice meeting and add it to the aged care visit template.
This is the part that prevents the next crisis, and it is the part most often skipped once the immediate pressure is off.