Monday, May 29, 2023
This activity is intended for primary care physicians, geriatricians, neurologists, and other physicians who care for patients with cognitive impairment.
The goal of this activity is to analyze ethical practices in decision making regarding screening tests among patients with cognitive impairment.
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CME Released: 10/21/2013; Reviewed and Renewed: 10/15/2015
Valid for credit through: 10/15/2016
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This case study is one in a series with commentaries by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee and the Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues not addressed in detail in the College's Ethics Manual, the Physician Charter on Professionalism, or other College position statements. The sixth edition of the ACP's Ethics Manual, the Physician Charter, and additional College policies on ethics, professionalism, and human rights issues are available at http://www.acponline.org/running_practice/ethics/ or by contacting the Center for Ethics and Professionalism at 215/351-2839.
Dr. Callen has a growing general internal medicine practice in a mid-sized city. Based on her medical training, her practice has attracted a higher than usual number of adult patients with cognitive disabilities, including patients who are residents of local group homes. She currently is considering whether to recommend preventive colorectal screening for two of her cognitively impaired patients, George Windom and Betty Paul.
George Windom is a 50-year-old man with developmental disabilities as a sequela of Haemophilus influenzae meningitis as a toddler. He lives in a group home where his mother, who is his legal guardian, visits him regularly. Mr. Windom is non-verbal, has very limited ability to cooperate with his care, and requires assistance in toileting. The director of the group home where Mr. Windom lives has called Dr. Callen to tell her that regulations governing the group home require that residents have a screening colonoscopy when they turn fifty. The director would like Dr. Callen to schedule Mr. Windom for the test. In considering options for colorectal screening for Mr. Windom, Dr. Callen consults with his caregivers at the group home. Staff members believe that a thorough preparation for colonoscopy would require Mr. Windom’s sequestration with an aide for up to 12 hours or his hospitalization and would cause Mr. Windom significant anxiety requiring sedation or other restraint.
Betty Paul is a 66-year-old woman with multi-infarct dementia. She has severe memory difficulties and evidences impaired judgment. She has no meaningful family support and has been cared for by an upstairs roommate and a network of home care providers including a longtime aide. She is able to offer little information about her family history. As far as Dr. Callen is able to determine, Ms. Paul has never undergone colorectal screening. Although she is unable to remember what Dr. Callen has told her from one meeting to the next, she appears to understand information provided by Dr. Callen about the purpose and nature of the screening but she says she feels fine and does not want to know if anything is wrong. She consistently refuses Dr. Callen’s recommendation for colonoscopy screening. Dr. Callen considers asking Ms. Paul’s longtime aide to “convince” her to undergo the test. What should Dr. Callen recommend regarding colorectal screening for Mr. Windom and Ms. Paul?
